Cataract Surgery With

Phaco and Femtophaco

Techniques

Lucio Buratto • Stephen F. Brint • Rosalia Sorce

SLACK Incorporated
 Lucio Buratto, MD
Centro Ambrosiano Oftalmico
Milan, Italy

Stephen F. Brint, MD, FACS

Associate Clinical Professor of Ophthalmology
Tulane University School of Medicine
New Orleans, Louisiana

Rosalia Sorce, MD
Senior Consultant
Operative Unit, Ophthalmology Department
Lentini Hospital
Siracusa, Italy
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ISBN: 978-1-61711-606-3

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Library of Congress Cataloging-in-Publication Data

Buratto, Lucio, author.
Cataract surgery with phaco and femtophaco techniques / Lucio Buratto, Stephen Brint, Rosalia Sorce.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-61711-606-3 (hardback : alk. paper)
I. Brint, Stephen F., 1946- author. II. Sorce, Rosalia, author. III. Title.
[DNLM: 1. Phacoemulsification--methods. 2. Laser Therapy--methods. WW 260]
RE451
617.7’42059--dc23
2013040620

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 DEDICATIONS
To my grandson, Kaito, wishing him a long and healthy life at peace with himself and those around him.

Lucio Buratto, MD

In memoriam Charles Kelman without whom this book would have been impossible.

Stephen F. Brint, MD, FACS

To my father, Pietro, and my mother, Anna, for their constant support. With infinite gratitude.

Rosalia Sorce, MD
 CONTENTS
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Foreword by Daniele Tognetto, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Section I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1 Phacoemulsification Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
Chapter 2 Anterior Chamber Phacoemulsification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
Chapter 3 Endocapsular Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
Chapter 4 Phaco Chop Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
Chapter 5 Microincision Cataract Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
Chapter 6 Irrigation and Aspiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
Chapter 7 Fluidics and Machines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
Chapter 8 Pumps of Newer Machines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
Section II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Chapter 9 Femtosecond Laser Cataract Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Stephen G. Slade, MD, FACS
Chapter 10 Femtosecond Laser-Assisted Cataract Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Pavel Stodulka, PhD
Chapter 11 The Role of Femtolaser in Cataract Surgery and Early Clinical Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Zoltan Z. Nagy, MD, PhD
Chapter 12 Femtocataract Surgery With B-MICS Sub 1 mm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Joaquίn Fernández Pérez, MD; Almudena Valero Marcos, MD; Marίa José Pérez Morales, DNP; and
Francisco Javier Martínez Peña, OD
Chapter 13 Laser-Assisted Cataract Surgery With the LenSx Femtolaser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Lucio Buratto, MD and Stephen F. Brint, MD, FACS

Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

 ACKNOWLEDGMENTS
The publication of a book is an extremely difficult and exhausting procedure and involves an incredible amount of
work. The completion of such an enterprise would not have been possible without the smooth-running organization and
the assistance of my reliable team of collaborators.
I would like to thank a number of them personally: Domenico Boccuzzi, Luigi Caretti, Mario Romano, Laura Sacchi,
and Rosalia Sorce for their invaluable contribution to the production of this series of books on cataract surgery. Heartfelt
thanks also to Massimiliano Crespi, the artist who produced the magnificent drawings, particularly for his unique ability
to transfer the author’s thoughts and ideas onto paper; my warmest thanks also to Salvatore Ferrandes who was in charge
of the iconographic and clinical aspects of the publications.
I would like to thank the staff of Medicongress, in particular Monica Gingardi, for their excellent organizational and
operational skills.
Sincere thanks to my dear friend Vittorio Picardo for his revision of the final version of the text.
Thanks are also due to SLACK Incorporated, my American publisher of the English versions, and their first-class work
in promoting the international distribution of the publications. Last but not least, I would like to thank my dear friend and
superb co-author Steve Brint for his immense work and invaluable contribution.

Lucio Buratto, MD
 ABOUT THE AUTHORS
Lucio Buratto, MD is a leading international expert in cataract and myopia surgery, and a pioneer in the ocular tech-
niques of intraocular lens (IOL) implantation, in the phacoemulsification procedure for the cataract, in the laser techniques
for myopia, astigmatism and hyperopia. In 1978, Dr. Buratto began using the Kelman phacoemulsification technique, and
in 1979 he started using posterior chamber intraocular lenses. Since 1980, he has organized and presided over 48 updating
congresses on the surgery of cataract and glaucoma and on laser therapy, organized 54 practical courses for the teaching
of eye surgery, and taken part as spokesman and teacher in more than 400 courses and congresses.
In 1989, Dr. Buratto became the world’s first surgeon to use excimer laser intrastromal keratomileusis, and concurrently
began to treat low myopia using PRK techniques. In 1995, he was appointed as Monitor of the United States Food and Drug
Administration. In 1996, Dr. Buratto became the world’s first surgeon to use a new technique called Down-Up LASIK,
which improved the LASIK procedure for the correction of myopia; he holds a United States patent for this technique.
For teaching purposes, Dr. Buratto has performed surgical operations during live surgery sessions for more than
200 international and Italian congresses, performed surgery during satellite broadcasts to 54 countries on 4 different con-
tinents, and designed and produced 143 instruments for ocular surgery. In 2004, he was a speaker at the Binkhorst Medal
Lecture during the XXII Annual Meeting of the European Society of Cataract and Refractive Surgeons (ESCRS) in Paris,
and was the first European surgeon to use the new intralase laser for refractive surgery. In 2011, Dr. Buratto was the first
West European surgeon to use the femtosecond laser for cataract surgery.
Dr. Buratto has published over 125 scientific publications and 59 monographs (of which 24 are on cataract surgery, 5 are
on glaucoma surgery, and 11 are on myopia). His recent works include, Phakic IOLs: State of the Art, LASIK: The Evolution
of Refractive Surgery, and PRK: The Past, Present, and Future of Surface Ablation.

Stephen F. Brint, MD, FACS was the first physician in the United States to perform the LASIK procedure in June 1991,
after working with Dr. Lucio Buratto in Milan to perfect the technique. He was the medical monitor of the first US FDA
LASIK study and has been a lead investigator for both the Alcon Custom Cornea LASIK procedure as well as the Medical
Monitor for all of the US FDA Wavelight Allegretto Wavefront Optimized and Custom Studies. He graduated from Tulane
University School of Medicine, New Orleans, Louisiana, and completed his residency there as well in 1977, continuing to
serve as Associate Clinical Professor of Ophthalmology. In addition to his vast LASIK experience of over 30,000 LASIK
procedures, many with the Intralase All Laser LASIK technique, he is a renowned cataract/lens surgeon, having partici-
pated in the FDA clinical trials of the new intraocular lenses including ReSTOR and ReZOOM, and toric IOLs.
He is board certified by the American Board of Ophthalmology and a Fellow of the American College of Surgeons. He
has been recognized as “The Best Doctor in New Orleans” by New Orleans Magazine for the past 10 years and has been
selected by his peers for the 2000–2012 editions of The Best Doctors in America. Dr. Brint is a leading cataract surgeon and
instructor, and the author of the 3 definitive textbooks on LASIK and cataract surgery, including the most recent Custom
LASIK.
Dr. Brint performs surgery and lectures around the world, including Europe, Russia, China, Japan, Australia, Singapore,
Africa, and South America.
Dr. Brint has a passion for education and research, and has been involved most recently with the refinement of the
intraoperative aberrometer for selecting IOL power and femtosecond laser-assisted cataract surgery.

Rosalia Sorce, MD graduated in medicine (summa cum laude) in 1992 from the University of Palermo, Sicily, and sub-
sequently specialized in ophthalmology.
Between 1997 and 2008, she was a consultant clinician in ocular diagnostics and surgery of the anterior segment at the
most important private health care clinics in Rome and Sicily.
In 2008, she was appointed senior consultant with the Healthcare Trust in the province of Siracusa, Sicily.
Since 2012, she has held the position of Senior Consultant for the operative unit in the Department of Ophthalmology
in the hospital of Lentini (SR).
She has published several books and is a member of numerous scientific associations.
 CONTRIBUTING AUTHORS
Almudena Valero Marcos, MD (Chapter 12) Joaquίn Fernández Pérez, MD (Chapter 12)

Marίa José Pérez Morales, DNP (Chapter 12) Stephen G. Slade, MD, FACS (Chapter 9)

Zoltan Z. Nagy, MD, PhD (Chapter 11) Pavel Stodulka, PhD (Chapter 10)

Francisco Javier Martínez Peña, OD (Chapter 12) Daniele Tognetto, MD (Foreword)

 FOREWORD
I learned how to remove cataracts during extracapsular extraction. I observed the skills and stole the knowledge from
my Maestro; I religiously followed all of the advice he gave me and put it into practice. However, I also learned by reading
and rereading the books written by Dr. Lucio Buratto, a Maestro who was unaware that he had become my tutor.
Many years have passed since then, and while reading this new book, I can still recognize his commitment and desire to
transmit to the reader a burning passion to fully understand all of the fine details of the surgical mechanisms and dynam-
ics associated with the technical and technological innovation.
Cataract surgery requires enormous precision and accuracy, in combination with profound knowledge and under-
standing of the surgical steps and the equipment used.
The cultural baggage of a surgeon deepens and matures over the years. So learning a new technique will allow him to
expand his armamentarium and have all of the appropriate tools available to him to confidently approach different clinical
situations; he will be able to pioneer and promote the development and application of the very latest techniques. According
to these principles, this book takes a fresh look at all of the main techniques proposed and employed over the years. This
has considerable importance because the choice of the most appropriate technique for each surgical step is an essential
component of the surgical planning as the various steps are all closely linked together.
Even the evolution of the phacoemulsifiers, with the development of new ways to supply the energy and the new devices
that improve the fluidness, has augmented the level of safety of the surgical procedure. Today it is possible to successfully
complete complicated operations by exploiting the innovative characteristics of the latest machines. Consequently, each
surgeon must learn about the new developments if he wishes to progress in his field.
The surgeon must learn everything there is to know about the physical principles that regulate the fluidness and the
energy flow to understand the machine’s specific operational mode to manage the different phases of surgery. It is essen-
tial that the surgeon understands which parameters can be modified during surgery and how they can be changed. The
detailed examination of the technical characteristics of the modern phacoemulsifiers reported in this book – thanks to
the enthusiastic input from Rosalia Sorce – is oriented in this direction and will be of great help to everyone who decides
to read the book.
Cataract surgery is always based on its precision and repeatability—it cannot move in any other direction. The dif-
fusion of the phacoemulsification technique bears witness to this development. The intuition of the great innovators in
ophthalmology, such as Dr. Lucio Buratto, was always driven by a desire to experiment the new possibilities offered by
technology. This was the case in the past with the transition from manual extracapsular surgery to the mechanized tech-
niques of phacoemulsification; and it is still the case today with the use of femtosecond laser machines in cataract surgery.
The comprehensive section in this book dedicated to femto-assisted cataract surgery once again shows the willingness
of colleagues to welcome something new—a feature that has always been present in Lucio Buratto’s scientific attitude. He
has always been passionate, yet never foolhardy, about the improvements in technology; on the contrary, he was acutely
attentive and highly critical of the developments.
The opportunity this book gives us to update our knowledge on such a revolutionary topic must be welcomed with
enthusiasm and gratitude, particularly at the present time when the implantation of advanced-technology lenses necessi-
tates extreme precision. With all probability, the road to perfecting the application of this highly sophisticated technology
will be a rocky one; however, surgeons will be able to achieve new, previously unimaginable heights of accuracy and safety
in their work.

Daniele Tognetto, MD
Professor of Ophthalmology
University of Trieste
Trieste, Italy
Section I

Phacoemulsification Technique
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
Every step of cataract surgery leads to the next; even all
those little, seemingly banal steps must be performed per-
fectly so as not to affect the final result.
Only once a good valved scleral tunnel has been created
in clear cornea, capsulorrhexis of a regular shape and size
has been made, and perfect hydrodissection and/or hydro-
delineation has taken place, does the key moment of the
procedure arrive—phacoemulsification.
Before we begin, however, there are a few basic concepts
that need to be clear:
1. Surgery is simplicity, necessity, elegance, and harmony
of movement; all “Baroque” notions of it should be
relegated to history.
2. A surgeon is like an airline pilot; he or she must have
high intellectual and personal capabilities, manual
dexterity, knowledge, the right attitude, and good
hand–eye coordination (Figure 1-1).
3. Operating is like playing chess or pool; you need to
know, plan, and “study” the moves needed for a suc-
cessful result (Figure 1-2).
The stages involved must therefore be as follows:
1. Knowledge: Surgery is not based on manual dexter-
ity alone. Without knowledge, what use would it be?
Results are based on a surgeon’s training and experi-
ence, which are irreplaceable. The study of the anatomy
of the eye, of the pathology of cataracts, and the knowl-
edge of surgical techniques and the machines and
materials used (viscoelastic, etc) are essential elements.
-3-
1
2. Observation: The difference between theory and reality
lies in the relationship between teaching and learning:
a well-taught phaco procedure is better than a well-
demonstrated procedure. In the latter, the sequence
of events may appear to be completely natural and
straightforward. It is, however, based on a full under-
standing of the logic behind every single step.
There are different phacoemulsification techniques, and
knowledge of each of these is essential for both understand-
ing various techniques and providing the ability to make
decisions that match individual strategies when dealing
with different types of cataracts.
Before emulsifying a cataract, we need to determine the
variables that will provide the highest probability of a suc-
cessful procedure; then we need to stop and ask: “What’s
important now?” We need to be pragmatic and always
remember to respect the anatomy and physiology of the eye.
A surgeon’s training must also include information on
the past because the past will also help us understand the
present and manage the future!
The ability to perform an extracapsular extraction, in
the event it is necessary to convert from a phaco procedure
that has become complicated, requires the mental maturity
to make decisions and the manual ability to know how to
enlarge the incision, to know how to use a loop, to perform
an anterior vitrectomy, and how to suture.
All of these maneuvers are learned from manuals and
books but perfected with practice. Just as the “workshop”
was the learning ground where apprentices watched the
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 3-5).
© 2014 SLACK Incorporated.
4  Chapter 1
Figure 1-1. The surgeon performing phacoemulsification is like
an airline pilot.
masters and learned all of the tricks of the trade, the operat-
ing room is the surgeon’s workshop. It is here that learning
surgeons apply what the books describe. It is said that sur-
gery is an art form and art will be beautiful when the head,
the hands, and the heart work together!
An eminent 19th-century clinician Armand Trousseau
concluded his lessons by announcing: “When you have
learned all there is to know about medical science, don’t
think that you are now doctors: not everyone is an art-
ist.” In the operating room, people become wise, wisdom
leads to caution, and caution is the result of experience.
Unfortunately, experience matures when caution has been
absent. However, experience alone is not enough!
In order to become a good cataract surgeon, it is essential
to understand the scientific reasoning, to be convinced of
Figure 1-2. Even the smallest details need to be planned for
a phacoemulsification operation. (Reprinted with permission
from R. Sorce.)
the need to follow the rules of the method, and to continue
studying and observing the leading masters. Self-control
is the first thing to learn when performing surgery: each
includes a number of steps that follow a predefined sequen-
tial order: phacoemulsification necessitates the same order
and harmony as a musical score. The surgeon must be able
to connect the manual gesture to the mental procedure.
Surgeons should never stop learning; the surgeon must
always keep abreast of the new developments and question
the depth of his or her knowledge. In other words, a sur-
geon will be a student for life.
True surgeons are born with special skills; they cannot
be trained to be artists (Table 1-1).
 Phacoemulsification Technique  5

TABLE 1-1.
SHORT HISTORY OF PHACOEMULSIFICATION
1962: Charles D. Kelman began studying his technique.
1967: Kelman performed the first procedure on a human eye.
1971: Cavitron produced the Cavitron/Kelman phacoemulsifier.
1972: David Paton and 4 other ophthalmologists took part in the first course of phacoemulsification in the
anterior chamber, run by Kelman.
1974: Dick Kratz and Bob Sinskey introduced the use of phaco in the posterior chamber.
1975: Kelman published his book on phacoemulsification.
1977: Steven Shearing of Las Vegas implanted the first intraocular lens (IOL) with J-loops in the posterior
chamber.
1978: Buratto began phacoemulsification in Italy, after Fabio Dossi and Franco Verzella.
1978: Several European hospitals purchased the phaco machine.
1979: The second Cavitron phaco machine was designed by Kelman.
1980: Daniele Aron Rosa and Franz Fankhauser introduced the Nd:YAG laser.
1980: David Miller and Robert Stegmann introduced Healon.
1984: The FDA approved the silicone IOL developed by Thomas Mazzocco and Edward Epstein.
1984: Gimbel and Neuhann introduced the capsulorrhexis technique.
1989: McFarland introduced the sutureless incision.
1989: Fine presented the phaco chip-and-flip technique.
1990: Gimbel was the first to present the divide and conquer technique.
1992: Nagahara introduced the phaco chop technique.
1993: Koch presented the stop-and-chop technique.
1995: Fine presented the chip-and-flip technique.
1998: Nichamin and Dillman introduced the vertical chop technique.
2005: The torsional phaco technique was developed.
2010: The femtophaco technique was developed.

Anterior Chamber
Phacoemulsification
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
In chronological order, the first phacoemulsification
technique of anterior chamber phacoemulsification was
introduced in the early 1960s by Charles D. Kelman, the
father of modern surgery.
Phacoemulsification was created from the need to extract
a large lens through a small incision, and the idea stemmed
from observation of an ultrasound apparatus used by
dentists.
Once the opening in the anterior chamber has been
made with a valved scleral tunnel and the anterior capsule
has been opened with a “can opener” or “Christmas tree”
technique, the lens can then be dislocated from the bag in
different ways (Figures 2-1 and 2-2):
1. First, with the horizontal or vertical “see–saw maneu-
ver,” the nuclear equator, freed from its adhesion
to the cortex, is brought to almost the center of the
anterior chamber then over the iris with the Kelman
technique. Second, a 25-gauge insulin needle is bent at
the tip with a needle holder so as to form a hook with a
60- to 70-degree angle used to engage the lens. In both
maneuvers, a slight degree of rotation is useful (Figures
2-3 and 2-4 and Table 2-1).
2. In the so-called “lollipop” technique, a short burst
of ultrasound power occludes the phaco tip into the
nucleus to stabilize it. The tip acts like a lollipop stick
surrounded by ice cream; this is an important maneu-
ver, as many other advanced phaco procedures use the
same basic principle (see phaco chop) (Figure 2-5).
-7-
2
3. In the “bed sheet” or “tire tool maneuver,” after the iris
has been gently retracted until the edge of the capsulot-
omy is visible, a cyclodialysis spatula or, better still, an
irrigating cannula with a chamfered tip is introduced
through the incision inside the capsular bag under
the nuclear equator in such a way as to “lift” it. The
procedure is facilitated by irrigation. The next step is
to maneuver the spatula in the opposite direction, thus
shifting the nucleus above the iris to complete the luxa-
tion procedure into the anterior chamber (Figure 2-6).
4. Hydrodissection separates the cortex from the capsule
and mobilizes the nucleus inside the bag. The proce-
dure involves inserting a straight or angled cannula
below the anterior capsule at the edge of the capsu-
lotomy for a depth of 1 to 2 mm. The edge is raised
slightly and a small quantity of balanced salt solution
(BSS) is injected until the fluid waves are observed in
the pupillary field. It will propagate to the opposite side
between the posterior capsule and the cortex.
The surgeon proceeds by gently compressing the nucleus
to allow the passage of liquid toward the equator and the
anterior cortex that detaches.
The cannula can be straight, flat, or angled. The angled
version (Buratto’s cannula) has the advantage of providing
the surgeon with excellent vision to control all of the details
of the procedure. The hook-tipped cannula facilitates the
dissection of the cortex from the capsule particularly below
the incision, an area that is generally more difficult to clean
during the aspiration of the residual cortical masses. Both
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 7-22).
© 2014 SLACK Incorporated.
8  Chapter 2

Figure 2-1. The “can opener” capsulotomy was used for years in Figure 2-2. The “Christmas tree” capsulotomy was the chosen
phacoemulsification. capsulotomy at the beginning of phacoemulsification and was
introduced by Charles D. Kelman.

A B

Figure 2-3. Vertical “see–saw maneuver” with “can opener” capsulotomy. (A) The Kelman cystotome is aimed distally and then
pulled toward the incision, lifting the lower equator. (B) The vertical movement should be followed by a slight rotation. (continued)
 Anterior Chamber Phacoemulsification  9

C D

Figure 2-3. (continued) (C) The maneuver is repeated, pushing the nucleus down and lifting the upper equator. This movement
must make it possible to free the adhesion to upper cortical areas; at the same time, it must release the equator from the capsular
bag from the top; then, it needs to interiorize it in the iris plane. To achieve the desired result, the maneuver needs to be repeated
2 to 4 times. (D) Next, the nucleus is lifted above the iris and then into the anterior chamber. The vertical see–saw maneuver is mainly
indicated for medium-hard and hard nuclei.

A B

Figure 2-4. Horizontal see–saw maneuver. (A) Indicated for soft nuclei. The maneuver is performed horizontally,
the cystotome is positioned at 3 o’clock or 9 o’clock near the capsulorrhexis. (B) The nucleus is moved to the
right and lifted. (continued)
10  Chapter 2

C D

E F

Figure 2-4. (continued) (C) The maneuver is repeated from the opposite side. (D) To release the remaining resi-
due from the nucleus, a slight rotation or vertical maneuver may be useful. (E, F) At the end, the nucleus comes
out of the capsulorrhexis and enters the anterior chamber.

of the cannulas, angled and hook-tipped, greatly facilitate
the rotation maneuvers, thanks to an excellent hold of the
nucleus.
The injection pressure and the quantity of fluid are not
important to achieving good hydrodissection. It is more
important to identify the right cleavage point and move the
cannula tip gently.
The liquid must be injected slowly, progressively, and in
a limited area to avoid excessive inflation of the capsular
bag and the possible rupture of the posterior capsule. When
the surgeon wishes to luxate the nucleus into the anterior
chamber, the amount of liquid injected must be greater but
controlled. For this option, the nucleus must be soft and the
rhexis must be large.
In these procedures, the capsulotomy must be as large
as possible so as to facilitate luxation of the nucleus in the
anterior chamber. At this point, the phaco procedure can
begin using different techniques such as “followability,”
“sector,” “carousel,” and “croissant.”
The first of these techniques uses the attraction of the
phaco tip (ie, its followability and the poor resistance of the
“soft” lens that allows the phaco tip to aspirate the cataract
material) (Figure 2-7).
THE SECTOR TECHNIQUE
The sector technique involves the emulsification of a
quadrant of the nucleus near the incision. Then, after rotat-
ing it 180 degrees, the diametrically opposite quadrant is
emulsified and then finally the residual components are
reduced to fragments. The logic behind this technique is
 Anterior Chamber Phacoemulsification  11

TABLE 2-1.
PHACOEMULSIFICATION IN THE ANTERIOR CHAMBER—KELMAN S TECHNIQUE
Phase 1: Preliminary steps ● Preparation of the operating field
● Isolation of the superior and inferior rectus muscles
● Instillation of methylene blue in the conjunctival sac to
reduce the conjunctival reflex during surgery
● Creation of a fornix-based flap
● Cauterization of scleral vessels near the limbus
● 3.1 mm incision at 12 o clock in the posterior third of the
surgical flap
● Injection of air into the anterior chamber
● Introduction of the Kelman irrigating cystotome with the
orifice towards the iris
● Wide, Christmas-tree capsulotomy, keeping irrigation from
the cystotome active

Phase 2: Mobilization of the nucleus ● See-saw maneuver, horizontal or vertical

● Impaling or lollipop technique
● Bed sheet or tire tool maneuver
● Hydrodissection

Phase 3: Fragmentation of the ● Sector technique

nucleus with ultrasound ● Carousel technique
● Croissant technique

Phase 4: Aspiration of the cortical ● Coaxial I/A

material IOL implantation ● PMMA anterior chamber IOL

to gradually reduce the central portion of the nucleus: the
surface, intermediate, and deep layers. Once the central
section has been split into 2 and the trench that unites the
residual nucleus has been fragmented, the smallest section
is emulsified followed by the larger portion. This technique
can be performed as a 1- or 2-handed procedure. In the
latter case, the spatula is introduced through the side port
and plays a complementary, subsidiary role to that of the
phaco tip in that it helps stabilize the nucleus and exposes
it better to the phaco tip while preventing undesired move-
ments. It also allows for more delicate, precise manipula-
tion in that it makes it easier to rotate the nucleus after a
sector has been emulsified and to expose another portion
of the equator. This method also favors the enlarging of a
previous incision and provides greater chamber stability
by limiting the number of phaco tip entries and therefore
subsequently improves the flow of the procedure and saves
time. Throughout the procedure, however, it is vital to
never lose sight of the second instrument. Although its use
offers numerous advantages, the second instrument must
never be allowed to distract the surgeon’s attention from
the main instrument—the phaco tip. The second instru-
ment can apply pressure and traction on the cornea and
iris when it is not being used in conjunction with the tip. It
can impede the surgeon’s view, cause damage to the cornea
or iris, or induce miosis. It can come into contact with the
phaco tip and cause damage that leads to metal fragments
circulating in the anterior chamber (AC).
This technique is ideal for nuclei of medium hardness
(3 to 4 degrees) (Figure 2-8).
THE CAROUSEL TECHNIQUE
The one-handed “carousel” technique1 is indicated for
nuclei of medium hardness (grade 2 to 3 degrees) with fairly
soft nuclear material. In practice, this technique consists
of introducing the phaco tip and directing it toward the
12  Chapter 2

A B

C D

Figure 2-5. “Lollipop” maneuver. (A) The U/S tip is aimed at the center of the nucleus and inserted in the nuclear material using
ultrasound; occlusion needs to be used to achieve a good “impaling.” (B, C) With the pedal in position 2 (without ultrasound), the
tip is used to move the nucleus first to one side then to the other in order to release it from the residue inside the capsular bag; it is
then brought into the anterior chamber. (D) The nucleus is in the anterior chamber.
 Anterior Chamber Phacoemulsification  13

A B

C D

Figure 2-6. Bed sheet or tire tool maneuver. (A) With a cannula with chamfered tip irrigating from the side, the iris is retracted gently
until the edge of the capsulorrhexis is observed; the capsule is also slightly retracted and the tip of the instrument inserted in the
capsular bag under the nuclear equator. (B) The cannula is introduced slowly under the nucleus and it is lifted at the same time;
the maneuver is made easier with irrigation. (C) The maneuver continues by directing the cannula toward 6 o’clock and moving the
nucleus above the iris in the area involved in the procedure. (D) The cannula is retracted and introduced from the opposite side to
repeat the same maneuver, which results in the complete luxation of the nucleus in the anterior chamber.
14  Chapter 2
A material is removed; if the nuclear residue is soft, the carou-
B THE CROISSANT TECHNIQUE
C
Figure 2-7. Hydrodissection. (A) After having introduced the
cannula under the edge of the capsulorrhexis, it is lifted toward
the anterior capsule endothelium and BSS is rapidly injected to
detach the nucleus from the cortex. (B, C) Once cleavage is com-
plete, the nucleus is luxated in the anterior chamber.
nuclear equator in a tangential position. Once the lens has
been engaged, ultrasound emulsification and aspiration
are performed in a slow continual fashion while the lens
is rotated like a carousel. This gradually reduces the size
of the lens until the tip can be used to remove the core of
the remaining nuclear portion. This maneuver must be
performed slowly because if the lens is rotated too quickly,
endothelial damage may occur. Bit by bit, all the equatorial
sel maneuver can be repeated. As an alternative, the “crois-
sant” technique can be used to engage the nucleus espe-
cially if the nuclear residue is a little hard. This technique
calls for particular attention and experience, as any oblique
positioning of the tip, as opposed to tangential, may create
traction near the incision and therefore create instability in
the chamber and cause the U/S tip to overheat due to poor
irrigation. In addition, the effects of ultrasound take place
outside the safety zone (ie, mostly where the depth of the
anterior chamber is less than that of the center and the iris
is nearer the U/S tip) (Figure 2-9).
The one-handed “croissant” technique involves emulsi-
fying a sector of the nucleus starting from the equator near
the tunnel (depending on the surgeon’s position, emulsifi-
cation begins at the 12 o’clock position or 3 o’clock, etc) and
moves from the surface layers to the deepest layers. The
lens is “sculpted” both laterally and distally and deepened
toward the center to form a sort of “croissant” or crescent
shape with its point in the middle. The croissant is then split
into 2 parts that are subsequently emulsified (Figure 2-10).
ANTERIOR CHAMBER TECHNIQUE
CONSIDERATIONS
Phacoemulsification in the anterior chamber is by far
the simplest technique for surgeons wanting to eliminate
any stress involved when the pupil constricts, which is a
frequent event if extreme delicacy is not employed. It also
helps prevent any possible rupture of the posterior capsule,
which is a complication to be avoided at all costs but which
lies in wait when carrying out the first steps inside the eye.
On the subject of steps, it is essential to be aware of the
fact that during cataract procedures, the surgeon needs to
be completely free to move all of his or her hands. A mistake
made “with the feet” is difficult to correct with the hands!
There is often a tendency to emulsify the section that
is easiest at that particular moment: this results in loss of
control of the procedure and the surgeon can find himself
“painted into a corner” with significant difficulty in remov-
ing nuclear fragments that are less accessible. In effect, it
is the eye that dictates the sequence of events during the
procedure.2
It is thus vital to understand the significance of the
various steps so as to resist the temptation to remove readily
accessible, apparently easy nuclear material.
For surgeons performing their first phacoemulsification
procedure, a specific approach is needed that facilitates
 Anterior Chamber Phacoemulsification  15

A B

C D

Figure 2-8. Sector technique: one-handed execution. (A) The nucleus is approached at the equator near the incision and is excavat-
ed until a piece of material is completely removed. (B) The U/S tip is removed and a spatula is introduced, which rotates the nucleus
180 degrees. (C) The U/S point is reinserted and another nucleus sector is excavated. The equator may be approached completely
and immediately or, alternatively, the first superficial layers can be removed, then the intermediate ones, and lastly the deep ones.
(D) The central section between the 2 excavated sectors is emulsified and then the 2 remaining pieces are dealt with; the last piece
is emulsified, preventing it from hitting against the endothelium. (continued)
16  Chapter 2

E F

Figure 2-8. (continued) Sector technique: 2-handed execution.

G (E) The nucleus is approached from the equator by the U/S tip,
the spatula helps to stabilize the nucleus and exposes it better
to the U/S tip. (F) Once a sector is emulsified, the spatula helps
to rotate the nucleus and exposes another portion of equator or
helps enlarge the previous excavation. (G) The nucleus is slowly
rotated 180 degrees and the sector opposite the initial one is
approached, the central section is dealt with, and the nucleus is
split into 2 parts; the smaller portion is emulsified first, then the
larger one next.

material to ensure this is the case). You must check the

condition of the edges and the degree of exposure of the
actual tip (that must be clearly visible but not too extended
from the sleeve). Check also the integrity of the sleeve and
the position of the irrigation openings (the silicone sleeve
should be positioned so as to leave the tip free by about
1.5 to 2 mm and the openings should be positioned later-
ally so that the flow is toward the 2 sides of the chamber to
be aspirated by the tip in the central position). The pedal
should be in position 1 (ie, in irrigation when checking that
all is working as it should).
There are 3 pedal positions: 1 = irrigation; 2 = aspiration;
access to the nucleus while protecting both the endothelium
3 = ultrasound emission (Figure 2-11).
and the posterior capsule from surgical trauma. In this
case, a few suggestions may be useful. The “back and forth” movements of the tip are induced
by the pedal: when the phaco tip is inserted in the cham-
Before starting, ensure good endothelial protection;
ber, the pedal should be in position 1 (ie, irrigation); dur-
inject a dispersive viscoelastic that will protect it; perform a
ing sculpting, use position 3 (ie, U/S) and when returning
large capsulorrhexis, efficient hydrodissection, and mobili-
to reposition the tip for the next step, use position 2 (ie,
zation; always use hydro- or viscoexpression of the nucleus;
aspiration).
and use a good 2-handed technique and a good phacoemul-
sification machine. It is often a good idea to consider the tip as an “ice cream
scoop” if you use a traditional phaco (eg, a phacoemulsifica-
Before inserting the U/S tip, make sure that the ante-
tion device that only has longitudinal movement [ie, where
rior chamber is deep enough (otherwise, inject viscoelastic
the tip only moves backward and forward]). When you are
 Anterior Chamber Phacoemulsification  17

A B

C D

Figure 2-9. “Carousel” technique. (A) The nucleus is already luxated in the anterior chamber. The U/S tip is inserted in the anterior
chamber and angled toward the equator with the pedal in position 2. Then, the ultrasound is started and part of the equatorial
material is fragmented. (B) Since the nuclear material is soft, it tends to adhere to the tip due to the aspiration effect. The nucleus
rotates (like a carousel) as it is removed. This maneuver must be performed slowly because if the lens is rotated too quickly, endo-
thelial damage may occur. (C) All of the equatorial material is slowly removed. If the nuclear residue is soft, the carousel maneuver
can be repeated at this point. (D) Alternatively, if the nuclear residue is hard, the “croissant” technique is used.

working with a “soft” nucleus, you can go deeper but extra
care needs to observed not to go “through” the nucleus. If
you are working with a harder nucleus, you can initially
emulsify a thin layer and then gradually sculpt to a greater
depth.
Different types of tips are available. They are usu-
ally made of titanium and can range from 1 to 0.9 mm
in diameter, are suited to ultrasonic vibrations, and have
remarkable resistance. The points of the tips can be angled
at 90 or 0 degrees or have tapered 15-, 30-, or 45-degree
edges. The choice of angle depends on the type of cataract
and procedure to be performed, not to mention personal
preference. The 0-degree point is used in the phaco chop
procedure; the 15-degree point is better for occlusion, the
18  Chapter 2

A B

C D

Figure 2-10. Kelman phacoemulsion “croissant” technique. (A) The nucleus is already luxated in the anterior chamber, the U/S tip
is put into contact with the nuclear equator, and a sector is emulsified. First, the surface layers are removed, then the intermediate
ones. (B) The excavation is sculpted both laterally and distally and deepened toward the center of the nucleus, then toward the
deeper layers. (C) By sculpting the excavation and deepening it a little at a time, the nuclear residue takes on a croissant appearance.
(D) The croissant is split into 2 pieces, which are then emulsified.

45-degree point cuts better, and the 30-degree angle is an
excellent compromise between the two. There are also anti-
cavitation points that reduce the presence of air bubbles
generated by turbulence during oscillation. We also have
angled points (Kelman, tapered, and mini 45-degree flared
versions), flared, mini-flared, mini-flared reverse, and
many others. Kelman tips with 12-degree angles are now
available that are even more elegant than their traditional
22-degree counterparts. While a straight tip tends to plane
lens material from the nuclear surface, a curved tip focuses
ultrasonic energy on the nuclear mass as well as performing
a “brushing” action thanks to its wide span (Figure 2-12).
An important thing to consider is that one of the most
influential factors for emulsification is the effectiveness of
the incision: the determining factor is the contact surface
area, where the greater the angle of the tip, the greater the
 Anterior Chamber Phacoemulsification  19

A B

Figure 2-11. (A) Position 0 = rest; position 1 = irrigation; position 2 = aspiration; position 3 = U/S. (B) Green: irrigation. Red: aspira-
tion. Blue: ultrasound.

A B

Figure 2-12. (A) U/S handle is composed of a probe containing a transducer connected to a titanium tip. The transducer can be
metallic (magnetostrictive) or crystal (piezoelectric). (B) The U/S tip in titanium has a diameter of approximately 1 mm, the aspiration
opening located at the point has a fluted edge, which can be 15, 30, or 45 degrees. (C) U/S tip at 0 degrees. (D) U/S tip at 30 degrees.
(E) U/S tip at 45 degrees. (F) Straight U/S tip. (continued)
20  Chapter 2

G H

I
J

K
L

Figure 2-12. (continued) (G) Angled U/S tip. (H) Various types of
U/S tips. (I) The phaco handle with U/S tip and part of the sleeve.
(J) Sleeve, U/S tip, and artificial test chamber. (K) Latest genera-
tion sleeve. (L) Kelman U/S tip with hole to reduce the possibility
of surge (ABS). (M) Operating procedure for Ozil tip.
 Anterior Chamber Phacoemulsification  21

cutting capacity, but the sharpest tips are the most dif-
ficult to occlude and therefore the efficacy of the vacuum
decreases. Also important is the type of phaco machine
and whether it is linear or not. The tendency is to work in a
linear fashion, also known as “surgeon control”; movement
of the foot controls irrigation, aspiration, and phacoemulsi-
fication, whereas the hands manipulate these functions, the
power of the phaco, and ultrasound activation times.
Another variable that must never be overlooked is fluid
dynamics. There are 2 principal aspects to be considered:
aspiration “flow rate” and “vacuum.” The former refers to
the amount of fluid that is removed from the eye through
the vacuum effect of the equipment, in effect, the “current”
inside the eye. This is measured in cubic centimeters per
minute; if the phaco tip is not occluded, the vacuum creates
the flow rate. If instead the phaco tip is occluded, the flow
rate ceases and the vacuum increases inside the aspiration
system until reaching a predetermined level. The vacuum is Figure 2-13. Correct position of the phaco tip compared to the
tunnel.
measured in mm Hg.
These concepts are vital in understanding the terms
of “followability,” meaning the capacity to attract, ie, the A key rule is that during phacoemulsification (ie, pedal
option of leaving the phaco tip in the safest possible posi- position 3), the tip must stay in the pupillary area also
tion and to capture the fragments you want by having them known as the “safety area,” where it is under close observa-
come closer as opposed to having to go search for them. tion and equidistant from the endothelium and posterior
This is a function of the aspiration flow rate: the greater capsule to avoid any damage that might occur following the
the current, the more easily residual lens material moves. mechanical action of the tip.
“Holdability” is the capacity of the cataract material to Even if obsolete, phaco in the AC is still used in certain
remain attached to the phaco tip on reaching occlusion: this situations:
is a function of the vacuum. ● Soft cataracts with spontaneous luxation of the nucleus
Entry to the anterior chamber can be made with a bevel- into the anterior chamber
down or bevel-up angled tip. The former is preferable where
the chamber is shallow to prevent tearing or detaching the ● Pseudoexfoliative cataracts with small pupils and loose
iris with subsequent risk of hemorrhaging and miosis that zonules
could compromise the subsequent steps of the procedure. ● Subluxation of the bag and/or rupture of the zonules
Once the chamber has been entered, the tip is rotated ● Miosis not permitting adequate visibility of peripheral
upward. Irrigation is not necessary, as the maneuver must lenticular structures
be preceded by the chamber being filled with viscoelastic.
The alternative is to make the entry with the phaco tip in ● Tears of the integrity of the capsulorrhexis (leaks)
the bevel-up position, thus avoiding rotation and therefore ● Rupture of the posterior capsule during phaco
formation of folds in the silicone sleeve. In this case, the
incision flap should be lifted with forceps to facilitate entry
and prevent damage to Descemet’s membrane. Irrigation is
recommended.
SUMMARY
Once inside the anterior chamber, phacoemulsification
During emulsification in the AC, it is essential to keep the
can begin. The formation of air bubbles is unlikely with
anterior chamber deep and this is the natural consequence
current machines but, should this occur, you will need to
of a delicate balance between irrigation, aspiration, and tun-
remove them immediately to prevent poor visibility. To
nel integrity. We also strongly recommend that you position
do so, point the phaco tip toward the bubbles in position 2
the tip bevel up (ie, with aspiration pointing upward) to
(aspiration). Never press the pedal in position 3 during this
ensure you do not damage endothelium with subsequent
maneuver, as you could severely damage the endothelium
corneal edema, which is the most potential complication of
and create even more bubbles. The U/S function must only
this technique and the main reason why the endocapsular
be activated when the tip is in contact with the nucleus
phacoemulsification technique was developed.
(Figure 2-13).
22  Chapter 2

REFERENCES
1. Kelman CD. Phacoemulsification and Aspiration: the Kelman
Technique of Cataract Removal. Birmingham, Alabama:
Aesculapius Publishing Company; 1975.
2. Jardine GJ, Wrong GC, Elsnab JR, Gale BK, Ambati BK.
Endocapsular carousel technique phacoemulsification. J Cataract
Refract Surg. 2011;37(3):433–437.
3. Dillman DM, William F. Maloney Attualita. in chirurgia della
cataratta – Facoemulsificazione. 1996. Verduci Editore 8:1:88-89.

Endocapsular Techniques
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
Before turning our attention to endocapsular tech-
niques, there are certain rules that need to be known and
followed, surgical maneuvers to be learned, and precautions
to be taken. These can be summarized as follows:
1. Care of the cornea: Providing such care is determined
by 3 factors: spatial, that is, the site where phaco is
performed in the posterior chamber with protection
of the capsular bag; mechanical, determining ultra-
sound (U/S) power level and deployment time; kinetic,
that is, phacoemulsification mode, meaning use of the
most appropriate technique with the most appropriate
parameters so as to reduce the total energy and turbu-
lence created during the phaco procedure.
2. Protection of the iris: All surgical maneuvers are
performed inside the capsular bag and are therefore
limited to a well-defined area without involving sur-
rounding anatomical structures. In reality, the edge
of the capsulorrhexis forms an important protective
diaphragm for the iris and prevents it from constrict-
ing during the procedure and decreases miosis stimuli.
3. Care of the anterior capsule and zonular area due to
capsulorrhexis and hydrodissection: The former pro-
vides a continuous circular capsular edge and therefore
a nonelastic entry that permits manipulation inside
the capsular bag without causing a radial tear of the
anterior capsule. It also reduces zonular stress, facili-
tating removal of peripheral lenticular residue without
leaving particles of the anterior capsule that block the
aspiration cannula opening allowing the nucleus to be
freed from inside the capsular bag. The latter, from a
mechanical-kinetic point of view, makes the lenticular
segments independent and decreases traction to the
- 23 -
3
zonular area. Capsulorrhexis is what draws the line
between surgical techniques. It separates the “older”
techniques from the new endocapsular ones (from
Gimbel in 1985 forward). The former techniques are
typified by opening the anterior capsule with the “can
opener,” “Christmas tree,” or envelope techniques, and
the nucleus is luxated in the anterior chamber before
phaco or remains in the posterior chamber and is
emulsified without prior hydrodissection. The latter
techniques only take place after a continuous circular
capsulotomy and appropriate separation of the nucleus
from the cortex and/or capsule and cortex. The tech-
nological progress in machines now lets us adjust the
operating parameters in real time to deal with differing
needs as they arise and make delicate (and even not so
delicate) maneuvers possible inside the bag.
THE LITTLE PHACOEMULSIFICATION
TECHNIQUE
This was the first variation of the original Kelman tech-
nique performed at the pupillary plane and created much
interest among surgeons. From the historical point of view,
it is an important development in that it demonstrated the
possibility of working with the phaco tip in an area that
was equidistant from the endothelium and the posterior
capsule, even if most of the surgery takes place near the pos-
terior capsule that becomes a site of potential risk. It is seen
as a compromise between the original technique developed
by Kelman and subsequent modern phaco techniques in the
capsular bag.
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 23-52).
© 2014 SLACK Incorporated.
24  Chapter 3
A B
Figure 3-1. (A) Technique under the irideal-supracapsular plane; bowl-type excavation of the nucleus. (B) Nucleus rotation
180 degrees using an olive spatula to clearly expose distally the portion not yet emulsified. (continued)
Various surgeons experimented independently with
this technique, but it was formally originated by Little and
Emery in 1979, then perfected by Shearing, Sinskey, and
Kratz.
This innovation is already seen in making the incision
in the scleral portion of the surgical flap in 2 planes, the
first orthogonal to the sclera and the second parallel to the
iris: this “indirect” incision provides a better seal for infu-
sion fluids, facilitates access to the pupillary plane in which
fragmentation must take place, and reduces postoperative
astigmatism.
It is essential to make a good tunnel because if it is too
large, the iris tends to occlude the incision and hinders the
natural escape of balanced salt solution (BSS), meaning that
burns, miosis, and increased ocular pressure may occur
in the tunnel. The technique is 2-handed and consists of
4 steps:
1. Central fragmentation in situ with the aim of creat-
ing a sort of concave–convex bowl by using shaving
movements to remove two-thirds of the thickness of
the nucleus, leaving it distally whole so that it acts as a
support for the spatula for the next step.
2. Subluxation of the nucleus into the pupillary plane: To
be performed as a 2-handed operation, the spatula is
introduced into the side port incision and the phaco
tip is retracted to the edge of the capsulotomy. At this
stage, keep the pedal in position zero, that is, with aspi-
ration and irrigation disabled. The chamber shallows
and the nucleus rises in the anterior chamber while
the spatula at 6 o’clock sets off a swinging motion that
luxates the equatorial portion in just the chamber at
12 o’clock near the phaco tip. When the proximal equa-
tor has been put in a sufficiently anterior position, the
U/S tip is advanced until it engages the nucleus at the
equator: at this stage, move the pedal to position 1 then
to position 2 with the double aim of keeping the luxated
nucleus in the anterior chamber by means of aspiration
and separating the cortical-nuclear adhesions in the
superior sector by means of irrigation (Figure 3-1).
3. Equatorial fragmentation: Used to remove a proximal
equatorial segment while the second instrument stabi-
lizes the nucleus and keeps it a little more elevated and
“available” for the phaco tip. Following this, the tip is
gently pulled backward with the pedal in position 2,
the nucleus is rotated with the spatula so as to pres-
ent a new equatorial segment to be emulsified and at
the same time to allow removal of the cortical-nuclear
fragment.
4. Central nuclear fragmentation: An important element
in this step is the action of the second instrument in
mobilizing the nuclear material, bringing it to the
phaco tip, and protecting the endothelium and the
posterior capsule from possible contact.1
This technique is particularly applicable with transpar-
ent cortex, a deep anterior chamber, a well-dilated pupil,
and medium-hard nucleus (Figure 3-2 and Table 3-1).

C D
E until achieving a large dimension, very thin bowl (side view).
BURATTO PUPILLARY PLANE
PHACOEMULSIFICATION TECHNIQUE
A variation of this technique is found in the Buratto
pupillary plane phacoemulsification technique, which is
typified by a scleral or short corneal tunnel with previous
entry into the chamber, a large capsulotomy with peripheral
sculpting near the incision (chamber filled with Viscoat),
and an initial stage of sculpting to excavate the superficial
part of the nucleus followed by superior, lateral, and slightly
distal deepening and widening of the excavation site, a
2-handed maneuver to luxate the nucleus with added pro-
tection from Viscoat in the chamber. Viscoat is used in case
of poor nuclear mobilization and can be injected above the
nucleus, inside the bag to induce or facilitate viscoluxation of
the superior heminucleus. Higher parameters are required to
facilitate engaging the nucleus at the equator (vacuum 60 to
Endocapsular Techniques  25
Figure 3-1. (continued) Technique under the irideal-
supracapsular plane. (C) Additional excavation of the nucleus
(D) Pressure on the nucleus is created at 6 o’clock, using the
spatula inserted from the paracentesis, first making it easier to
lift and then engage the equator. Start of the equatorial emul-
sification phase. Initially the pedal is kept in the zero position
and the nucleus is captured in the equatorial site. At this point,
irrigation is restarted to obtain a flow of fluid under the nucleus
and further separation from the cortex and posterior capsule.
The emulsification maneuver is repeated several times until the
nuclear equator is completely removed. Finally, the nuclear resi-
due is emulsified. (E) Removal of the cortex remnant.
120 mm Hg, flow 15 to 22 ml/min, linear U/S); the advanced
step involves equatorial emulsification by means of vacuum
for better occlusion of the material and the last fragment of
the nucleus is emulsified and aspirated (Table 3-2).
THE MALONEY POSTERIOR CHAMBER
PHACOEMULSIFICATION TECHNIQUE
Phacoemulsification at the pupillary plane is a com-
promise between the Kelman and posterior chamber
techniques.
The Maloney posterior chamber phacoemulsification
technique was first described in 1988 and is an evolution of
the previous technique.2
The new part is that of performing most of the phaco-
emulsification under the iris plane. The incision is positioned
in the cornea, creating a self-closing tunnel; the nucleus is
sculpted in a bowl fashion, rotated 180 degrees with a spatu-
la, and the sculpting is repeated until a thin layer of material
remains inside the bag. When the circle has been completed,
a small portion of nucleus remains, the dish, which is emul-
sified in the posterior chamber with the help of a spatula
and short bursts of U/S. It is at this point that the difference
between the pupillary plane technique can be fully appreci-
ated compared to the Maloney technique: residue from the
nucleus is only minimally luxated in the anteroposterior
26  Chapter 3

A B

C D

Figure 3-2. Technique on the pupillary plane. (A) The nucleus is sculpted into a bowl in the proximal and central part. The removal
of material must be extensive and deep enough. The nucleus is left intact distally. (B) The spatula is inserted from the lateral para-
centesis and then the U/S tip is retracted to the limit of the capsulorrhexis. At this point, the pedal goes to zero (thus aspiration and
irrigation are disabled) so that the chamber flattens and the nucleus tends to rise in the anterior chamber. (C) The spatula presses
at 6 o’clock (or in the direction opposite the main tunnel) and holds the nucleus in place in that area so only the proximal equator
detaches from the capsular bag and rises in the anterior chamber in part due to suspension of the irrigation. When the proximal
equator is sufficiently interiorized, the U/S tip is moved forward until capturing the nucleus at the equator. At this point, the pedal
must be in position 1 (irrigation) and then in position 2. Then phaco starts. (D) The emulsification removes a proximal equatorial
sector while the spatula stabilizes the nucleus and keeps it slightly raised and “available” for the U/S tip. (continued)
 Endocapsular Techniques  27

E F

Figure 3-2. (continued) (E) The nucleus is rotated 20 to 40 degrees to expose another sector to emulsify to the U/S tip.
Phacoemulsion continues again with the support of the spatula, which stabilizes the material and exposes it to the tip. (F) The last
piece of the nucleus is emulsified with or without the spatula. Thus, most of the emulsification has been performed at the irideal
plane.

plane. It is important to avoid sudden, uncontrolled move-
ments of nuclear material that might damage the posterior
capsule and endothelium. This technique is riskier than the
Little’s technique and calls for machines with good chamber
stability (Figure 3-3 and Table 3-3).
In the techniques described so far, the nucleus is emulsi-
fied from the anterior surface or from the periphery with
sculpting movements made with extensive use of U/S and
little occlusion used until the final stages of the procedure.
They are undoubtedly simple to perform in cases of soft or
medium cataracts but become potentially dangerous with a
medium/hard cataract as surgical times become longer to
the detriment of endothelial integrity.
Because of this problem, a mixed technique originated
that included sculpting grooves, nucleofracture, engaging,
and emulsifying the fragments (Table 3-4).
THE GIMBEL DIVIDE AND
CONQUER TECHNIQUE
In 1986, Gimbel3,4 suggested fragmenting the nucleus
into assorted pieces with his “divide and conquer” tech-
nique (nucleofracture), which was later modified and orga-
nized better by Shepherd as the “in situ” or “four-quadrant”
technique (Figure 3-4).5
The name comes from the Latin divide et impera,
whereas nucleofracture stems from the Latin prefix nucleo
and the Greek suffix fractis meaning to fracture. The
underlying principle of nucleofracture is the creation of
“breakages” to split the lens into nuclear portions that are
small enough to be extracted through a small incision and a
5-mm capsulorrhexis is then fragmented one after the other
while under optimal visual control using short bursts of U/S
and causing as little trauma as possible to the eye. It also
allows medium-hard or very hard nuclei to be phacoemul-
sified without having to resort to overly high U/S power
settings over long periods. There are 2 variations of the
procedure: the “groove technique” for medium-hard nuclei
and the “crater technique” for hard nuclei.
To fully understand this technique, you need to remem-
ber the anatomy of the lens and especially the relationship
between the fibers and the sutures. The lens consists of
3 main elements: the capsule (or crystalline lens or capsu-
lar bag), the subcapsular epithelium, and the parenchyma.
The parenchyma itself is made up of an external cortical
layer (or cortex) and a nucleus that is completely surround-
ed by the cortex. The cortex never stops developing even
in the postnatal stage and therefore, with age, undergoes
significant changes to its thickness, transparency, and
elasticity. By the end of the sixth week of life, an embryo
has already formed primitive lenticular fibers that then go
on to build the embryonic nucleus. In the meantime, new
fibers originate from the equator (secondary lenticular
fibers), wrapping layer after layer around the embryonic
nucleus. This growth process leads to the formation of
the fetal nucleus that, at the puberty stage, contributes to
the formation of the infantile then the adult nucleus and
the cortex surrounding it. During embryonic growth,
28  Chapter 3

TABLE 3-1.
PHACOEMULSIFICATION IN THE PUPILLARY PLANE—LITTLE S TECHNIQUE
Preamble It is the first technique to be applied in the posterior chamber. The procedure was
developed and fine-tuned by various authors, including Emery, Shearing, Sinskey, and Kratz
Nucleus Particularly suitable for moderately hard nuclei (grade 3)
Incision Limbal, posterior
Capsulotomy Can opener, various kinds: D-shaped, H-shaped, triangular, round
Phase 1: Central ● No preliminary maneuvers are performed on the nucleus before starting phacoemulsi-
fragmentation fication. The parameters used were the fixed ones of the devices of the time (vacuum:
40, flow: 20, U/S adjusted by the surgeon)
● Shaving, that is, removal of the superficial layers using only one-third to half of the tip s
orifice
● About half or two-thirds of the nucleus is sculpted, creating a bowl. Sculpting is not
extended distally to leave a part of the nucleus, which will be used in the next phase,
to rest the spatula on
Phase 2: ● The U/S tip is retracted, in proximity of the incision
Mobilization of ● The spatula is inserted through the accessory incision and positioned at 6 o clock distally
the nucleus in the to the U/S tip in the nuclear groove created in phase 1
pupillary plane
● Put the pedal in position 0 to stop irrigation and reduce chamber depth. In this way,
the part of the nucleus proximal to the incision rises (and the distal one is lowered with
the spatula)
● The U/S tip moves forward and captures the nucleus at 12 o clock, then the pedal is
pressed to position 1 and then 2
Phase 3: Equatorial ● After fixing the nucleus, the surgeon fragments the proximal equatorial portion (30 to
fragmentation 40 degrees)
● The spatula is then used to rotate the nucleus, the maneuver is repeated, and another
equatorial portion is exposed to the U/S tip
● More rotation and fragmentation until all the nucleus equator is removed and the inner
central portion remains
Phase 4: ● The spatula is used to mobilize the nucleus residue and to expose it to the U/S tip that
Fragmentation of fragments it in the anterior chamber
the central residue

the lenticular fibers arrange themselves in an overall
anteroposterior position. They elongate and unite to form
2 Y-shaped sutures: one upright anterior and an upside
down posterior. Over time, these fibers are added to and
arrange to form more complex sutures that are oriented
in different directions creating potential cleavage planes
that are susceptible to fracture, especially regarding those
that are radially arranged. The epithelial cells deposit in
concentric layers that become more dense in the center
and softer at the periphery. This arrangement of layers
resembles that of a tree trunk or an onion (Figure 3-5).8
To summarize, the lenticular nucleus is arranged
in radial and lamellar zones that form layers that are
susceptible to separation with the use of appropriate instru-
ments into smaller, more easily managed segments for
phacoemulsification.
The creation of fractures inside the nucleus to facilitate
removal of the cataract through a small incision creates
minor trauma to the eye and requires an opening of the
anterior capsule that is resistant to the tension that separa-
tion procedures tend to create.
This occurs with the development of continuous cur-
vilinear capsulorrhexis that provides a strong edge, as it is
geometrically the most resistant form of a circle.
 Endocapsular Techniques  29

TABLE 3-2.
PHACOEMULSIFICATION IN THE PUPILLARY PLANE—BURATTO S TECHNIQUE
Technique Used Between Modifications to the Technique
1980 and 1987
Incision Sclerocorneal or limbal Short scleral or corneal tunnel, with
almost immediate entry in the chamber
Capsulotomy ● Can opener ● Large capsulorrhexis with peripheral
decentralization near the incision
● With BSS
● Chamber filled with Viscoat
Initial Shaving first, followed by deep sculpting ● Shaving then sculpting
phacoemulsification in the proximal and central portion of the
phase nucleus. The procedure is gradual and
progressive. The groove is deep if the nucleus
is hard, less extensive if soft. The distal portion
of the nucleus remains essentially intact
Intermediate Bimanual maneuver for nucleus luxation: ● Like in the past, with the added
phacoemulsification Olive-tip spatula at 6 o clock
●
protection offered by Viscoat in the
phase anterior chamber
Retraction of the U/S tip toward the
●
● Chance to induce or facilitate the
incision behind the proximal limit of the
luxation of the superior seminucleus
equator
by injecting Viscoat in the superior
● Pedal in the zero position to let the region of the sac
chamber flatten
● Higher parameters can be used
● Slight pressure at 6 o clock with the to make it easier to capture of the
spatula to cause the nucleus to rise at nucleus at the equator:
12 o clock
‒ Vacuum: 60 to 120
● Tip moves on and impales the proximal
‒ Flow: 15 to 22
equatorial nucleus
● Pedal in position 1 and immediately after ‒ Linearly adjustable U/S
in position 2
Advanced ● Equatorial emulsification of a sector Equatorial emulsification is performed
phacoemulsification ● Rotation of the nucleus with the spatula using higher vacuum to have more
phase contact with the material
● Emulsification of another proximal sector
Terminal ● Emulsification in the anterior chamber of The residual nuclear material can be
phacoemulsification the nuclear residue that is mobilized with captured via occlusion with the U/S tip
phase the spatula

The “divide and conquer” technique is indicated for hard
nuclei and requires hydrolineation. The technique is split
into 4 stages5,6:
1. Phaco settings: The first groove is created with moder-
ate levels of U/S energy and low aspiration and vacuum
parameters. It is important that the phaco tip is not
completely occluded during the creation of the groov-
ing that must be delicate. If you use a peristaltic pump,
the suggested parameters are as follows: 60% U/S,
60 mm Hg vacuum, and 25 to 30 mm Hg of aspiration.
If instead you use Venturi technology, the settings
should be 60% of U/S and 250 mm Hg of vacuum.
These parameters allow you to delicately create the
groove and gradually deepen it without extracting
nuclear material and thus avoiding significant move-
ment of the lens.
2. Sculpting of a groove involves the following:
The central site starts near the incision and works
toward the distal portion using only about one-third
of the opening of the tip and sculpts the first groove
30  Chapter 3

A B

C D

Figure 3-3. Phacoemulsification in the posterior chamber.

(A) The nucleus is sculpted into a bowl. Then it is rotated
E 180 degrees with the spatula. The excavation is repeated
distally. (B) Rotation of the nucleus to expose a new portion
of the U/S tip. (C) The emulsification involves the central and
equatorial material in order to leave a nuclear dish with uniform
thickness. (D) The spatula is inserted from the access point and
presses slightly on the nucleus at 6 o’clock (or 9 o’clock, based
on the tunnel site), making it easier to first lift and then capture
the nucleus at the equator. Then emulsification of the superficial
equatorial sector is performed. The maneuver requires good
synchronization: the pedal goes to the zero position, the U/S
tip is retracted to the limit of the capsulorrhexis, the spatula
presses slightly at 6 o’clock, lifting the equator to 12 o’clock. The
tip is moved forward and engages the equator. Then irrigation
is restarted and fluid passes under the nucleus and separates
it from the external cortex and/or posterior capsule. (E) At this
point, the equatorial nucleus is emulsified. The maneuver is
repeated as many times as needed to remove all of the nuclear
equator, then the nuclear dish residue is emulsified.
 Endocapsular Techniques  31

TABLE 3-3.
PHACOEMULSIFICATION IN THE POSTERIOR CHAMBER—MALONEY S TECHNIQUE
Classic Technique Technique Performed
According to Buratto
Incision Lateral pocket Short scleral tunnel
Capsulotomy Can opener With superiorly decentered
capsulorrhexis
Initial Shaving and sculpting with a 30-degree tip and Sculpting with the same technique
phacoemulsification 50% to 80% U/S but using Viscoat as protection and
phase Overlapping grooves are created on the setting the parameters as follows:
material surface pushing in 40% to 50% of the ‒ Vacuum: 0 to 20 mm Hg
U/S tip. The sculpting is slowly made deeper,
‒ Flow: 10 to 13 mL/min
until it is as deep and extensive as possible
(70% to 80%) ‒ U/S can be adjusted using
The nucleus still adheres to the cortical material the pedal according to
and the capsule, which has an important nucleus hardness (high
function̶it acts against the action of the U/S power in any case)
tip, which makes emulsification more effective
At the end of the sculpting process, the
nucleus must have the shape of a concave‒
convex bowl
The author does not supply the parameters to
use on the device
Mobilization of ● Performed with spatula and U/S tip ● U/S tip only; before performing
the nucleus ● With a maneuver similar to that used in the the maneuver, hydrodissection,
or viscodissection with Provisc
technique in the pupillary plane, with the
or Viscoat is performed (there
nucleus rising less (the nucleus has been
is capsulorrhexis and not can
cut more deeply and extensively in the
opener capsulotomy)
distal portions)
● With a combined movement that includes
pushing and rotating clockwise and
anticlockwise with the spatula (and with a
little help from the tip if necessary)
Emulsification of ● While the spatula is used to depress distally, ● The procedure can be made
the equator and the U/S tip engages the nucleus simpler by using the device s
of the plate ● Emulsification of the proximal portion is parameters adequately:
performed ‒ Vacuum: 60 to 120 mm Hg
● Followed by nucleus rotation ‒ Flow: 10 to 15 mL/min
● With the spatula at 6 o clock the plate is ‒ Linear, low-power U/S
pressed downward, the equator is hooked ● The plate is removed via
with the U/S tip and emulsification is occlusion of the U/S tip
performed
‒ Vacuum: 40 to 60 mm Hg
‒ Flow: 10 to 15 mL/min
‒ Linear, low-power U/S
32  Chapter 3

TABLE 3-4.
A
CLASSIFICATION OF
ENDOCAPSULAR TECHNIQUES
Techniques Without Nucleofracture
1. Endocapsular by Shepherd
2. Intercapsular technique
3. Bimanual endocapsular phacoemulsification
(cut and suck technique)
4. Four-quadrant Shepherd s technique
5. Chip-and-flip technique
Mixed Nucleofracture Techniques
1. Divide and conquer technique
2. In situ fracture technique
3. 2 to 4 fractional technique
4. Chip-and-flip technique
Pure Nucleofracture Techniques B
1. Phaco chop technique
2. Phaco-drill or bevel-down phaco chop
technique
3. Choo-choo chop and flip-phaco technique
4. Stop-and-chop technique
5. Quick chop phaco technique
6. No vacuum chop technique

toward 6 o’clock (or 9 or 3, in relation to the incision

site). Near the periphery, taking great care to avoid any
contact between the tip and the edges of the capsulor-
rhexis and with the iris, as this may create zonular
traction and possible miosis that are both sources of
complications.
The length must extend to just below the capsulor- Figure 3-4. “Divide and conquer” technique. (A) Creation of
rhexis. If hydrodelineation has been used, the groove the trench with evaluation of its site, length, depth, and width.
must proceed as far as the edge of the hard nucleus. (B) Fracturing or cracking. (continued)
If, instead, you have only performed hydrodissection,
that is, the separation of the endonucleus and the cor-
tex, the groove can extend further but not as far as the
about 50% of the required depth on the first passage;
equator.
the third trench to about 75% of the depth, leaving
The depth varies depending on the consistency of the further deepening a possibility; the fourth groove can
nucleus. The depth is obtained through a series of back be sculpted to about 80% to 90% of the required depth.
and forth movements of the tip that gradually removes The number of rotations varies depending on the
nuclear material—usually at least 80% of the thickness surgical technique used and can be 30 to 40 degrees
of the nucleus. Construction of the groove should be or 90 degrees and can change from 1 to 4. The type of
layer-by-layer to avoid damage to the posterior cap- sculpting, however, depends on the type of cataract.
sule: the first and second grooves can be sculpted to The depth also varies in relation to hardness of the

C D
Figure 3-4. (continued) (C) Removal of quadrants.
(D) A 180-degree rotation of the heminucleus. (E) Additional
E cracking.
nucleus: a soft cataract usually has just a “sticky” cor-
tex that is not easily separated from the nucleus and
tends to crumble. To avoid this situation, you need to
compensate for a soft nucleus and leave more lenticular
material for the spatula to engage. Next, perform 2 or
3 passes in the central nucleus to break the edge and
leave room to position the spatula. Alternately, with
hard nuclei, you need to sculpt as deeply as is safe and
as distally as the pupil allows.
A handy method for assessing the depth of the groove
is to compare it with the diameter of the phaco tip.
Given that the average thickness of a lens is 4.5 mm
Endocapsular Techniques  33
and that the diameter of a phaco tip varies from 1 to
0.9 mm (standard points) and the sleeve measures
1.5 to 1.6 mm, simply make sure that the groove is no
more than twice the diameter of the tip. The recom-
mended parameters are as follows: vacuum 0 to 20 mm
Hg, flow rate 10 to 20 mL/min, and U/S power setting
about 60% to 70%.
The color of the lenticular material is a reliable indica-
tor as a change from gray to pink indicates that you are
nearing the cortex and therefore the capsule.
It is essential at this stage that the pedal remains in
position 2 or 3 to stabilize the fluidics and to prevent
fluctuation of the anterior chamber that might provoke
movement of the iris and thus provoke intraoperative
miosis.
In short, the groove is like a deep valley with steep
sides. The depth is more important than the width,
which should be one and a half times the size of the
phaco tip for cataracts with a medium nucleus. In real-
ity, the width too, like the depth, varies depending on
the hardness of the nucleus. Very soft nuclei can be
treated in 2 different ways or with a very narrow groove
the same size as the phaco tip for the four-quadrant
technique or with a very wide groove, over twice the
size of the phaco tip for fragmentation in 2 quadrants.
Very hard nuclei need very wide grooves that are over
twice the size of the tip. As a rule, the groove needs
to be a little wider than the phaco tip so as to have
34  Chapter 3

A B

Figure 3-5. Anatomy of the lens. (A) Lamellar organization.

(B) Visible from the inside to the outside the embryonic nucleus,
fetal nucleus, infantile nucleus, and adult nucleus, the cortex.
(C) The lenticular fibers, arranged in anterior–posterior direction,
C unit to form 2 Y-structures. Other fibers are added over time and
arrange themselves to form more complex layers that lie in dif-
ferent directions.

In practice, the tip passes just under the lower edge of

sufficient room to position not just the U/S tip but also
the second instrument inside it.
The choice of whether to split the nucleus into 2 or
4 quadrants depends on both the hardness of the nucle-
us and personal preference. As a guideline, you should
split the nucleus into several parts: into 2 halves if they
are soft, into 4 if they are medium-hard, and into 4 to
6 if they are hard. Otherwise, you can simply split them
down the middle.
Your movements in constructing grooves must be in
harmony with the anatomical structure and you should
therefore remember that the lens is biconvex in shape
and has a naturally convex form in the central and
inferior sections.
The key to a stress-free procedure (for both the cap-
sule and the surgeon) is to create the central groove
as deeply as is safely possible (ie, until the red reflex
is visible). While sculpting, use the underlying cortex
as a safety point of reference to protect the posterior
capsule.
the anterior capsule, keeping a central position without
ever nearing the capsular periphery because experience
teaches that it is the most threatening area where we
are not used to working. Visibility is poor in this vul-
nerable area that is also awkward to reach with the tip.
Movements are gradual, and we must take care to not
occlude the tip or pierce the nucleus while proceeding
with a sort of sculpting–shaving layer-by-layer action
until we reach the posterior face of the lens where we
find the Y-shaped suture (Figure 3-6).
Once the first half of the central groove has been
made, the nucleus is rotated counterclockwise by 90 or
180 degrees with a one-handed motion or along with
the phaco tip, and the second instrument that was
previously introduced through the lateral paracen-
tesis. The ease with which this maneuver is carried
out depends on the success of the hydrodissection (in
particular) and the hydrodelineation. Again, in practi-
cal terms, with completion of the hydrodissection, the
surgeon must make sure that the nucleus can be eas-
ily rotated inside the bag. The nucleus and cortex can
rotate as a single entity or independently of each other.
The important thing is that the rotation is easy. If this
is not the case, repeat the hydrodissection. During this
step, it is advisable to keep the pedal in position 1 (irri-
gation) to facilitate rotation.
3. Fracturing or cracking: This is a key moment in the
“divide and conquer” technique. You have to position
the phaco tip (that at this moment is being used as a
maneuvering instrument) and a spatula introduced
through the paracentesis into the depth of the groove
or better to two-third of the depth to create the best
leverage and, using a transverse action with minimum
 Endocapsular Techniques  35

A B

Figure 3-6. Different ratios between U/S tip and nuclear

material. (A) Cutting or shaving the material: The tip almost
C shaves the nucleus and is only occupied for one-third of its
lumen. Regardless of the U/S power, it can only remove a little
material with each passage; however, each passage can be very
fast. (B) Sculpting: The lumen is occupied half to two-thirds; thus,
the tip can remove a fair amount of material, if there is enough
U/S energy. Thus, the progression of the tip, even if dependent
on the hardness of the material it encounters, has to be slow.
(C) Occlusion: The tip is completely obstructed by material. The
flow is then disabled and the vacuum rises in the aspiration
line until reaching the maximum preset value. The tip cannot
advance and remove material unless the material is very soft.
This situation, tip impaled in the nucleus, is used to luxate the
nucleus (carefully) in the bag, or keep it still while another instru-
ment (chopper) acts on it.

force, perform a “gentle” separation, thus creating a
breakage from the periphery to the center; the maneu-
ver must be slow but decisive. At this stage, keep the
pedal in position 0. It is often easier to position the
phaco tip in the deepest part of the groove followed
by the immediately adjacent second instrument that is
manipulated using a rolling motion between the thumb
and index finger to prevent distortion of the paracen-
tesis: the action is of a rotating—not pulling—nature,
as the latter would cause deformation of the cornea or
a shifting of the eye that would hamper visibility. Any
pushing or pulling near the tunnel or incision site can
increase ocular pressure and, as a consequence, cause
the collapse of the anterior chamber and potential rup-
ture of the posterior capsule (Figure 3-7A).
All this means is that you have to divide the nucleus.
Sometimes you divide the cortex at the same time,
sometimes it remains intact and acts as a protective
cushion for the posterior capsule (obviously depending
on the hardness of the nucleus).
It is important that the fracture goes beyond the medi-
an line and involves nuclear material of full thickness
so that the quadrants are free from one another. The
fracture can be performed in 2 different ways:
a. With a crossed over or counter positioned action,
in which the phaco tip and the second instrument
are positioned perpendicularly to the groove to
offer the best leverage; each instrument is pushed
toward the opposite wall; the phaco tip is positioned
and pushed to the left (for right-handed surgeons),
whereas the spatula is used to exercise pressure on
the opposite wall of the groove; then, the nucleus
rotates (by 90 degrees) and the maneuver is repeated
for the other 3 grooves (Figure 3-7B).
b. With a parallel action in which the phaco tip and
the second instrument are positioned at the bot-
tom of the groove; the phaco tip is placed against
the right wall, and the second instrument against
the left wall; they are then separated in a parallel
motion that easily divides the nucleus. Obviously,
the groove must be in line with the central point
between the main incision and the side port inci-
sion; following this, the nucleus can be made to
36  Chapter 3

A B

Figure 3-7. (A) Nuclear division procedure. The nucleus is divid-

ed with 2 instruments: the U/S tip pushes toward the right while
the spatula pushes toward the left. The 2 instruments must be
positioned at the same depth (approximately two-thirds of the
nucleus thickness) inside the groove, in the third distal of the
groove (after breaking, they can be moved to the central third
to enlarge the cracking). The separation action must be synchro-
nized. (B) Nuclear division procedure with crossed instruments.
The U/S tip pushes toward the left while the spatula pushes
C toward the right. (C) Nuclear division procedure with parallel
instruments. The U/S tip pushes toward the right while the
spatula pushes toward the left.

can be brought in sequence to the central part of the

4. Removal of quadrants: This takes place in a systematic
rotate to line up with the other grooves, and then be
divided in the same fashion (Figure 3-7C).
Fracturing without rotation can be performed by
combining 2 techniques.
The different segments can be brought to the center of
the capsular bag after each has been fractured or they
can be left in situ until the separation is finished: the
latter is preferable for very hard nuclei so that the poste-
rior capsule is kept well-distended during the stages of
sculpting, fracturing, and rotation to prevent possible
rupture. Once separation is complete, the quadrants
capsular bag for safe, efficient phacoemulsification.
fashion starting from the quadrant sitting opposite the
incision site. The phaco tip is positioned very close to
the top of the quadrant to be removed. If this position
is unobtainable, a short burst of U/S will help it adhere
to the phaco tip. At this stage, the pedal should be
in position 2, allowing the vacuum level to reach its
maximum preset value. The tip is then plunged deeper
into the nucleus with another short burst of U/S. With
this one-handed technique, the nucleus can be grasped
and rotated clockwise or counterclockwise with a push
and rotatory movement of the U/S tip. The portion of
nucleus can now be lifted and brought to the center for
emulsification. The typical settings for removing quad-
rants are 60% U/S power, 350 mm Hg vacuum, and
25 mm Hg aspiration when using peristaltic technol-
ogy and 60% of U/S power and 350 mm Hg of vacuum
for machines with a Venturi pump. U/S power can be
increased or decreased in relation to the density of the
nucleus. In reality, a U/S energy level of 60% is not like-
ly to be used and, in any case, should be left to expert
surgeons. If the surgeon encounters difficulty with
segments of unequal sizes, the most sensible approach
is to remove the smallest piece first. This is in reality
the easiest to grasp and, once removed, creates more
“working space” for removing the larger fragments.

Sometimes a residual piece is a half and impossible to
split any further. A surgeon’s experience would prompt
him or her to luxate it into the anterior chamber, then
remove it carefully with the help of a chopper. During
this stage, it is best to work in the pupillary center
with the aid of a dispersive viscoelastic substance that
has the dual role of protecting the endothelium and
facilitating the surgical maneuver.
Once the first quadrant has been removed, the
same procedure is repeated for the other quadrants.
Fragmentation takes place from the surface portions
and the deep portions at the nuclear equator: each
successive portion to be emulsified is presented to
the phaco tip with a delicate rotary movement that
pushes the nucleus at the same time. At this stage, the
spatula plays a vital role in stabilizing the quadrants as
it mobilizes (facilitating movement to the center) and
positions them correctly (thus creating good position-
ing between the tip and the material, and facilitating
occlusion). It also contributes to maintaining contact
between the quadrant and the tip if the piece should
slip or if the vacuum is insufficient. It also protects the
endothelium and the posterior capsule from sharp-
edged debris rotating in the anterior segment and
facilitates by stabilizing and aligning the last quadrant
that remains free to “float” inside the bag.
During fracturing, you can operate in different ways:
• With the pedal in position 0 (irrigation off): in the
presence of a very deep anterior chamber or a large
lens to more easily position the most suitable depth
with the 2 instruments. A further advantage is that
the posterior capsule loses its tension and relaxes,
thus diminishing the risk of laceration. The nucleus
and all the contents of the bag tend to rise due to
the shallowing of the chamber and the effect of the
pushing force exercised by the vitreous.
• With the pedal in position 1 (irrigation on): this
allows sufficient space to be maintained in cases of
large, hyperopic, or glaucomatous nuclei, or where
the anterior chamber is shallow.
• The use of a viscoelastic substance: this allows both
the push from the vitreous to be decreased and helps
prevent miosis. It also improves visibility, stabilizes
the anterior chamber, and facilitates the fracture.
When used to fill the bag, it creates a sort of “sand-
wich,” forming a layer above the posterior capsule
(pseudoepinucleus) and a layer above the nucleus
that protects the endothelium, creating fragments
are more stable and easier to rotate.
• The use of prechoppers to fracture the nucleus: these
are inserted in the groove with closed arms that
are then separated to create the fracture. Here the
Endocapsular Techniques  37
anterior chamber must be filled with a viscoelastic
substance.
• With a chopper: A hook-shaped device creates a
mechanical fracture in the nucleus without first
having to make a groove (chop phaco). The benefit
lies in not needing to create a groove, which means
decreased U/S and shorter procedures (Figure 3-8).
To grasp and emulsify the quadrants, all the phaco
parameters need to be set to match the density of the nuclei
so as to allow good “followability” and “holdability,” (ie, to
increase the flow rate to allow the nucleus to approach the
phaco and to increase the vacuum for emulsification and
aspiration).
In practice, you need to place the tip against the mate-
rial, activate aspiration and wait for occlusion and then for
the vacuum to reach its maximum preset value.
If the cataract is soft, aspiration will be enough to pro-
vide occlusion. If instead the lens is hard, spontaneous
occlusion will be less likely and short bursts of low-power
U/S will be needed to engage the nucleus. The fragment is
thus brought to the pupillary center and emulsified: trac-
tion toward the center is performed slowly and gradually
and should ideally be supported by the second instrument
that helps free the quadrant from adjacent material.
Occlusion and emulsification take place with short
bursts or pulses of U/S and the material is kept under con-
stant control with the use of the spatula.
The best site for occluding the nuclear fragment to be
emulsified differs depending on the size and hardness of
the nucleus and the size of the capsulorrhexis.
In general, the superficial portion of the nuclear quad-
rant is relatively soft, whereas the central and deep part of
the wedge is harder, and that closest to the posterior capsule
is made up of medium-hard material.
If the nucleus is not very hard and the capsulorrhexis is
large, the phaco tip can be positioned near the groove with
the angled edge in contact with the quadrant. Simply wait
until it occludes and grasp the nuclear fragment, then bring
it toward the center of the pupil. If the nucleus is hard and
the quadrants therefore have sharp edges, it is best to lift
the deep portion of the quadrant with a second instrument
and position it near the surface. This allows the tip to easily
grasp the top of the nucleus (where the material is soft) to
achieve occlusion, and to move the quadrant to the center
to be emulsified. If the phaco tip is positioned in the portion
of fragment that is too near the surface it will spin along its
own axis in such a way that the top of the nucleus revolves
toward the posterior capsule, causing it to rupture.
Young surgeons often have difficulty removing
quadrants, as they are unable to separate them well enough
and unable to create the amount of vacuum needed to
attract pieces of the nucleus to the center of the pupil. The
manual dexterity needed to approach a lens fragment—to
deploy a micro-pulse of U/S, grasp and stabilize the piece
38  Chapter 3
A
Figure 3-8. (A) An example of Nagahara’s Chopper hook that creates a mechanical fracture in the nucleus without previous creation
of a trench. (B) Use of the chop in phaco chop.
of nucleus, position it for occlusion, and then return
position 2 to aspirate it—requires months of practice, par-
ticipation in many teaching procedures, and development
of the ability to master the technique.
THE SHEPHERD CROSS-TYPE, FOUR-
QUADRANT, OR IN SITU NUCLEAR
FRACTURING
A variation of the original Gimbel technique, the
Shepherd method,5 has become so widely used that it has
earned the epithet “divide and conquer.” The in situ frac-
ture is a practical procedure that splits the nucleus into
4 quadrants, fracturing, and then removing them one after
the other. Shepherd realized that the technique of fractur-
ing the “nuclear ring,” developed by Gimbel, was seen by
many surgeons as difficult and off-putting, so he modified
the technique to make it less complex and more acceptable.
Shepherd proposed creating 2 intersecting grooves that
split the nucleus into 4 small quadrants that could be easily
made by fracturing not just the peripheral ring but also the
posterior plane in order to remove each of the small quad-
rants in order.
There are variations of this technique to deal with nuclei
of different degrees of hardness. For instance, sculpting
or removing the cortical surface and epinucleus may be
employed to visualize the nucleus itself and then to cre-
ate a central groove from the incision to the diametri-
cally opposite edge of the capsulorrhexis if the nucleus is
B
medium-hard. If the nucleus is hard, the surface is aspirated
and then sculpting is performed to create a central portion
that is about 90% of the width and depth of the nucleus
and about twice as wide as the phaco tip (ie, one and a half
times the width of the tip with the sleeve). Care must be
taken not to move the quadrant too much, especially if the
innermost tips are pointing toward the posterior capsule.
Soft cataracts do not fracture easily, but fold, and can be
easily aspirated with the phaco tip. In cases of small pupils,
this technique can also be applied, as the grooves allow the
tops of the quadrants to be seen.
As in other techniques, the design of the groove must
respect the anatomy of the lens: the groove should be on
the surface at the start, deepen toward the center, and
return to the surface toward the distal portion. Grooves
must be contained within the capsulorrhexis. If you want
to expand them, you can explore the ends with the use of
a spatula and push the nucleus toward the incision or in
the opposite direction. As soon as the first hemigroove has
suitable depth and width, the nucleus is rotated clockwise
90 degrees with the second instrument and the second
hemigroove is created perpendicular to the first. During
rotation, the pedal must be in position 1 so that the capsule
distends and the nucleus can float freely. During this stage,
the spatula serves to stabilize the nucleus. A new hemi-
groove is then created (a continuation of the first groove)
perpendicular to the previous one, and then a fourth one
is made to form a cross. After each groove has been made,
the nucleus is rotated 90 degrees and the grooves are then
gradually deepened until the desired depth is reached.
Once the cross is sufficiently deep and wide, separation
can begin. As with other nuclear fracturing methods, to

allow for regular separation without excessive traction, the
phaco tip and the second instrument must be positioned
quite deep in the groove in the middle portion of the arm
of the cross in either a crossed or parallel position. The
fracture takes place with the pedal in position 0 and must
include the full depth of the nucleus with no residual nucle-
ar material between the wedges. After the first fracture
has been made, the nucleus is rotated 90 degrees and the
maneuver is repeated for each quadrant until the nucleus
has been split into 4 portions of nuclear material. When
the perpendicular fracture lines are complete, the nucleus
forms 4 wedge-shaped quadrants that can be individu-
ally emulsified. If the nucleus is medium-hard, it is best to
remove the central tops of the quadrants with a shaving
maneuver to provide the phaco tip with good support for
occlusion performed with short bursts of U/S. The nuclear
quadrant can then be brought to the center of the capsular
bag to finish fragmentation.
If the nucleus is medium-hard to very hard, there are
2 possible courses of action: (1) With the pedal in position 0,
release the bag and the posterior chamber shallows, as does
the central part of the quadrant, due to the effect of being
pushed by the vitreous. The quadrant can also be elevated
with the use of the spatula. When it is in a good position,
place the phaco tip into contact with it and attempt occlu-
sion with either suction or with short bursts of low-power
U/S to bring it into the pupil center for emulsification.
(2) With the pedal in position 2, use the second instrument
to lift the lower edge of the wedge, and then use the phaco
tip to grasp the bottom part of the quadrant and bring it to
the center of the capsular bag. The quadrant must always
be emulsified in the central position, inside the bag, or in
the anterior chamber. Its movements can, and must, be
controlled by the spatula that stabilizes them to facilitate
the action of the phaco tip. The maneuver is repeated for the
other 3 quadrants until they have all been removed. The last
segment of the nucleus can present some problems, as it is
no longer held in position in the capsular bag by the pres-
ence of other wedges and can tend to float. In this event,
the spatula can be of great assistance in controlling the
movement of the remaining quadrant and in maneuvering
it toward the phaco tip and protecting the posterior capsule.
The next stage is to remove the cortex (Figures 3-9 and 3-10
and Table 3-5).7
CHIP-AND-FLIP
PHACOEMULSIFICATION
Chip-and-flip phacoemulsification, as proposed by
Howard Fine, utilizes a circumferential division of the
nucleus in the endonucleus, hard central mass and epi-
nucleus, defined by Blumenthal as “the material you find
Endocapsular Techniques  39
between the true cortex and the endonucleus.”6 This is a
protective component for both the corneal endothelium
and the capsular fornices because this technique plays
a large role in emulsification and therefore buffers the
amount of mechanical energy directed to the posterior
capsule and zonules.
The epinucleus offers the advantage of keeping the bag
distended, preventing forward movement of the posterior
capsule and potential rupture.
The epinucleus appears as a lamellar amorphous mate-
rial with an intermediate degree of maturity between the
true cortex and the endonucleus. Based on its status, cata-
racts can be classified as follows:
● Soft cataracts—Composed almost exclusively of true
cortex and an epinucleus with no material that has
reached sufficient maturity to be called endonucleus
● Medium cataracts—Composed of a central endonucle-
us that occupies more than 50% of lenticular volume
and surrounded by a good epinucleus that is in turn
surrounded by a layer of true cortex
● Ultra hard cataracts—Almost exclusively very dense
brunescent cataracts (the denser they are the more scle-
rotic they are) surrounded by a very thin layer of true
cortex with or without a small amount of epinucleus
It is important not to confuse the concept of “maturity”
with longevity!
This technique lets you operate in safety in nearly the
entire center of the pupil that is the deepest part of the
capsular bag and in the presence of easily recognizable ana-
tomical landmarks, the hydrodelineation cleavage ring or
“golden ring” and never in depth near the posterior capsule,
capsular fornix or below the iris.
It is the ideal technique for medium-to-softer cataracts
with nuclei that are not very large.
The versatility of this procedure is such that it can be
safely and reliably performed through any well-prepared
phaco incision in any site (Figure 3-11).
The last advancement is a temporal incision in clear cor-
nea, as it presents the following benefits:
● The eye drains naturally from the outer edge and the
surgeon therefore rarely needs to work underwater.
● If there is slight corneal flattening around the wound,
the temporal position is the farthest from the visual
axis.
● The wound is parallel with the line of blinking and
with gravity.
● The temporal position ensures adequate exposure of
the limbus and facilitates the whole procedure.
The important steps in the technique are (a) hydrodis-
section wherein care must be taken to inject the fluid
below the capsule and toward the equatorial periphery so
40  Chapter 3

A B

C D

Figure 3-9. The Shepherd cross-type, four-quadrant, or in situ nuclear fracturing. (A) Capsulorrhexis and hydrodissection have
already been performed, the U/S tip is used to shave the cortical and epinuclear material in the area defined by the capsulorrhexis.
(B) The central trench is excavated. (C) First a hemitrench is created from 12 to 6 o’clock (or from 3 to 9, based on the surgeon’s posi-
tion). It needs to have a width corresponding to a diameter and a half compared to the sleeve. The nucleus is rotated 90 degrees
with the spatula, (D) then another hemitrench is created distally. The maneuver is repeated another 2 times. (continued)
 Endocapsular Techniques  41

E F

G H

Figure 3-9. (continued) (E) Thus 4 cross-type hemitrenches are created that are perpendicular to each other. (F) The nucleus is
rotated further and the trenches are progressively deepened until a red reflection is seen. (G) Final rotation of the nucleus before
the fracture. (H) First fracture with parallel instruments. (continued)
42  Chapter 3

I J

K L

Figure 3-9. (continued) (I) Additional rotation of the nucleus after the first fracture. (J) When the remaining thickness of the materi-
al is 10% to 20% of the total nucleus thickness, the fracture is performed with the tip and the spatula, which are placed at two-thirds
of the trench depth. (K) The nucleus is then rotated and fractured again. It is important that the nucleus is opened to the deepest
layers. (L) Removal of the last nucleus fragment. Be careful to place the phaco tip in bevel-up position.
 Endocapsular Techniques  43

A B

C D

E F

G H

Figure 3-10. Four-quadrant phaco. (A) Once the capsulorrhexis is performed, the epinucleus is shaved with the U/S tip. (B) The first
groove is started in the nuclear material. (C) The nucleus is then rotated and the second groove is started distally. (D) The nucleus
is then rotated and the second part of the groove is made. (E) The cross is completed. (F) The nucleus is divided into 2 parts with
a chopper and the U/S tip. (G) The nucleus is then rotated and divided into 2 other pieces. (H) Emulsification of the 4 quadrants.
44  Chapter 3

TABLE 3-5.
FOUR-QUADRANT NUCLEOFRACTURE—SHEPHERD S TECHNIQUE
Nuclei Hardness: grade 2 to 3, even 4
Tip 45 degrees
Parameters* ● Low vacuum in the initial phase, intermediate-high in the capture phase
and intermediate in the next phases
● U/S high at the beginning and low toward the end
Incision Corneal or scleral tunnel
Viscoelastic substance Viscoat
Emulsification Shaving of cortical material and the epinucleus inside the capsulorrhexis
Initial phase without occlusion
Creation of the first ● Emulsify starting from the proximal edge of capsulorrhexis and
semigroove and its features proceeding toward the distal one
● Width: 1.5 times the diameter of the sleeve
● Deeper in the center, shallower at the periphery
● Contained in the limit set by capsulorrhexis
Creation of the second ● The nucleus is rotated by 90 degrees with the spatula
semigroove ● Creation of the second semigroove, slightly deeper than the first; nucleus
rotated again
Creation of the third and They are the direct continuation of the first and second semigrooves
fourth semigrooves
Making the first, second, The 4 semigrooves are made deeper until they reach three-fourths of the
third, and fourth semigrooves depth of the nucleus
deeper
First nucleofracture With the spatula on 1 side, and the U/S tip on the other, the distal groove is
fractured
Second̶third̶fourth ● 90-degree rotation, followed by fracture
nucleofracture ● 90-degree rotation, followed by fracture
● 90-degree rotation, followed by fracture
Capture and fragmentation of ● Occlusion-capture of the quadrant with pedal in position 2
quadrants ● Transport from the equator toward the center followed by emulsification
*The author does not include the parameters in the original article.

as to leave a thin layer of cortex adhering to the peripheral
capsule and (b) hydrodelineation, the formation of which is
assured by the appearance of a golden ring that matches the
line of demarcation (Figure 3-12).
Hydrodelineation is performed preferably before
hydrodissection so as to better evaluate and delimit the
central nucleus from the epinucleus. The endonucleus
is then sculpted from the center of the pupil to the golden
ring that delineates the epinucleus using a sculpting motion
or the occlusion technique with vacuum levels set at zero or
very low so as to form a nuclear “dish” that is as concave as
possible. Next, with the spatula inserted from the side (the
side changes in relation to the surgeon’s position superior
or temporal and depending on whether the surgeon uses
the right or left hand), the nucleus is gently shifted toward
the incision, keeping the phaco tip in the central position
so as to be in contact with the inner edge of the distal
nuclear equator and the opposite part to then be emulsified.
Bringing the nucleus toward the incision while perform-
ing emulsification of the periphery protects the capsule
distally; in effect, the part of the nucleus being emulsified
is moved away from the capsular fornix and the iris. The
emulsification occurs just below the anterior capsular rim
near the center of the capsulorrhexis (ie, in the safest area).
 Endocapsular Techniques  45

A B

C D

E F

Figure 3-11. Chip-and-flip technique. (A) After capsulorrhexis, an accurate hydrodissection is performed. (B) And then an accurate
hydrodelineation to correctly delineate or almost mobilize the central nucleus from the epinucleus. (C) The central nuclear portion is
sculpted, which is rotated and emulsified in the center. (D) With the spatula inserted from the access incision, the nucleus is moved
toward the incision and the U/S tip captures the equatorial edge of the nucleus distally and emulsifies it. The nucleus is rotated again
and the procedure repeated. With the U/S tip in occlusion applied to the distal portion of the endonucleus and using the spatula,
the nucleus is rotated from bottom to top to be brought to the center of the capsulorrhexis and fragmented inside the capsular bag;
the epinucleus protects the posterior capsule. (E) The nucleus is moved toward the incision and the U/S tip captures the equatorial
edge of the nucleus distally. (F) The U/S tip in occlusion is brought into contact with the distal portion of the epinucleus using a
spatula. (continued)

The nucleus is then rotated clockwise to emulsify a new seg-
ment as far as the golden ring while the phaco tip is always
kept in the central position. The whole equatorial edge of
the endonucleus is thus removed, meaning all 360 degrees
of the nucleus.
Once the anterior half of the endonucleus has been
removed, the spatula is inserted inside the golden ring
created with hydrodelineation on the left side of the
peripheral portion of the ring and the chip is slid under
the endonuclear remnant (ie, under the nuclear remnant
inside that is then lifted and brought to the center of the
bag or to the capsulorrhexis for emulsification). Using the
spatula, the “chip” is easily removed, preferably with use of
pulsed bursts of U/S. The whole maneuver is facilitated by
the synergetic action of the phaco tip that pushes the chip
46  Chapter 3

G H

Figure 3-11. (continued) (G) Only the epinucleus remains, which is captured with the tip in occlusion and rotated with the spatula
(flip) until bringing the captured part to the center of the capsular bag. (H) The epinucleus is then aspirated and emulsified little by
little inside the capsulorrhexis.

B
A

Figure 3-12. (A) Hydrodelineation: separation of the epinucleus from the nucleus, testified to by the appearance of a golden ring.
(B) Golden ring obtainable with hydrodelineation.

down and toward the incision to enlarge the golden ring at
the periphery and make access easier for the spatula that,
once in position under the chip, lifts it toward the center
of the bag or to the level of the capsulorrhexis. When the
spatula enters the left edge of the golden ring and moves
under the chip, the phaco tip can help push the chip upward
on the spatula, facilitating its dislocation and positioning
its upper edge near the central part of the capsular bag.
At this stage, the tip of the epinuclear dish is both quickly
and safely removed from the capsular fornix from the
opposite side of the tunnel. This is achieved by pulling the
epinuclear edge from the incision site toward the opposite
side and thus facilitates removing the edge from the fornix
at about 5 or 6 o’clock (in the case of a superior incision).
Alternatively, you can achieve the same result with another
maneuver by pushing the center of the dish toward 5 or 6
o’clock if the surgeon is in a superior position, or toward 8
to 9 or 3 to 4 o’clock (in relation to the right of left eye), if the
surgeon is in the temporal position, to make the dish slide
out from the fornix and under the distal part of the anterior
chamber. Next, using the phaco tip, the epinuclear dish is
pulled from 5 to 6 (or 8 to 9/3 to 4) o’clock to 12 o’clock (or
3 or 9 o’clock), that is, toward the tunnel. This is performed
with the aid of the spatula that, pushing toward 5 to 6 o’
clock, makes the epinucleus “flip.” This maneuver does not
always work at the first attempt and often has to be repeated
several times with the dish having to be rotated before every
new attempt. The movements made by the spatula and the
phaco tip on the epinucleus must fold it over on itself then
turn it upside down so that the equatorial portion posi-
tioned distally from the incision is brought to the center
of the capsular bag and then to a more accessible position
that, very importantly, is far from the posterior capsule.
Once the flip maneuver has been performed, the bowl
can be removed safely. The distal edge of the epinucleus is
grasped by phaco tip occlusion with the pedal in position
2 and is then brought to the center of the capsulorrhexis
to be removed with aspiration that is sometimes aided by
low-power emulsification. The procedure is repeated until
only the last segment remains. This is rotated in the distal
portion, elevated by the phaco tip with the pedal in posi-
tion 2 and brought toward the incision while rotation of the
 Endocapsular Techniques  47

TABLE 3-6.
CHIP-AND-FLIP PHACOEMULSIFICATION—FINE S TECHNIQUE
Nuclei Suitable for nuclei with 2 to 3 degrees of hardness
Incision Superior corneal tunnel
Capsulotomy Small-diameter capsulorrhexis
Viscoelastic substance Viscoat
Hydrodissection and Both are performed. For the correct execution of the technique, it is important that,
hydrodelamination through hydrodissection, the central nucleus is well separated from the epinucleus
and that the whole nucleus rotates easily
Phaco sculpting ● Vacuum 10 to 50; flow 10 to 15; U/S power 70%
● The anterior portion is sculpted as normal
Phaco moving of the ● The central nucleus is moved upward with the spatula, exposing the lower edge.
nucleus The aim of the maneuver is to move the portion that needs to be emulsified
away from the posterior distal capsule
● Emulsification of the inner edge of the equator at 6 o clock
Rotation of the nucleus ● The aim of the maneuver is to bring another portion of the nuclear edge in the
with the spatula 6 o clock position
● Next, the edge is captured at 6 o clock and phacoemulsification follows
● The maneuver is repeated until the entire edge has been emulsified
Phacoemulsification of ● The residual nucleus (chip) is lifted from below with the spatula, moved to the
the nuclear chip center of the sac, and then fragmented
Flip of the epinucleus ● Occlusion of the tip in the epinucleus, distally
● Combined maneuver using the spatula and the U/S tip to lift and rotate the
epinucleus and position it in the capsulorrhexis
● Phacoemulsification of the epinucleus in a safe site
Parameters of the flip ● Vacuum 100 to 150
● Flow 20
● U/S power 50%

remaining portion of the epinucleus takes place at the cen-
ter. At the same time, the deepest plane of the epinucleus is
brought toward the distal part of the bag with the second
instrument. This maneuver creates antiparallel forces and
causes the epinucleus to flip after which it is removed from
the proximal part to the posterior capsule. It is removed
in this flipped position through aspiration only or using
low-power phacoemulsification. Ideally, if hydrodissection
has been appropriately performed, the epinucleus and the
cortex are both removed in this way.
The advantages of this technique lie in the fact that the
phaco action takes place in the central part of the capsular
bag (ie, in the so-called “safety zone” while all the emul-
sification occurs in the “hydrodissection ring”). With the
emulsification of the internal nucleus, a sort of cushion
remains that is made up of the epinucleus and periph-
eral cortex that protects the capsule-zonular structures. In
addition, it also has a buffering effect on the epinucleus and
limits the amount of mechanical energy transmitted to the
posterior capsule and the zonules also in cases wherein the
U/S values needed to emulsify the central nucleus are nec-
essarily very high. This technique is typically used for the
removal of medium-hard nuclei (Table 3-6).2
CRACK-AND-FLIP TECHNIQUE
This is a variation of the chip-and-flip method in which
splitting the nucleus is replaced by fracturing the central
nucleus.
The incision can be superior or temporal.
The endonucleus and epinucleus, obtained from hydro-
delineation and hydrodissection, must be treated as 2 sepa-
rate entities with 2 different philosophies and techniques.
48  Chapter 3
The first stage is superficial shaving followed by creating
grooves (as in other phaco techniques).
There are 4 steps for dealing with the endonucleus:
the first is to split the nucleus into 2 halves; the second is
to split the halves into quadrants; the third is to remove
each quadrant in sequence; and the fourth is to leave the
epinucleus as intact as possible. Splitting the endonucleus
begins with creating a deep groove confined to the center
of the endonucleus and this groove must not reach the
hydrodelineation golden ring; however, before starting, you
need to choose the right parameters that will let you work
efficiently, in safety, and ask yourself, “What’s important
now?” The right answer is “the effectiveness of the cut.”
The first central groove is made with quick, short bursts
of phaco that groove the endonucleus and do not occlude
it. In this step, it is not important to go deeply, but rather
to extend the groove to the peripheral limit of the endo-
nucleus, respecting the natural concavity of this area and
the edge of the capsulorrhexis. Once the first segment of
the groove has been completed, the endonucleus is rotated
180 degrees and then the central groove is made going
progressively deeper. Remember that the harder the endo-
nucleus, the deeper the groove must be. At this stage, you
can now proceed with splitting the endonucleus by placing
2 instruments (the phaco tip and the spatula) at the bottom
of the trench and applying force toward the bottom and the
periphery; this maneuver should be performed smoothly,
but if this is not possible you must not use force but rather
return to the central groove and deepen or widen it as nec-
essary. Once the endonucleus has been split in half, rotate it
90 degrees and then make another groove deeply and dis-
tally from the center of this half in preparation for splitting
it into quadrants. The creation of this groove should follow
the same guidelines as those for the central one; the depth
should be equal while its length need not necessarily go as
far as the periphery, as is the case with the main groove.
On completion of the second groove, the endonucleus is
rotated by 180 degrees (it is usually easier to rotate the half
while still intact). Next, make the third groove, which is
found deeply and at the center of the second: it is much
easier to reach a good depth as you are working inside
the second groove and not on the top of the endonucleus.
Once all the grooves have been created, you need to stop
for a moment and inspect all of them to check the depth
and peripheral extension, then proceed with the attempt
to separate the endonucleus into 4 quadrants. If you are in
any doubt, reposition the endonucleus and deepen, enlarge,
or extend the grooves. The philosophy of this technique is
that the grooves and cracking should be complete before
removing a quadrant from the endonucleus. In this way,
the capsule will remain as extended as possible and will
provide more room in which to maneuver in safety. As
already mentioned, splitting can occur in different ways:
either crossed or with parallel instruments. In the latter
case, the second instrument can be introduced through the
side port incision or from the main tunnel and be placed
in the groove alongside the phaco tip. The fracture without
rotation is performed by combining the 2 techniques (use-
ful if there is a tear in the capsulorrhexis). Once the split-
ting into quadrants process has been completed, you can
start to remove the endonuclear quadrants that must be
completely free to make the procedure safe and easy to per-
form. You need to make sure that there are no endonuclear
connections that bind the quadrants together, especially in
the thickest part of the endonucleus. Instead of trying to
force the quadrants apart in situ, you should return to the
grooves and deepen or enlarge them as necessary. To facili-
tate the removal of the quadrants, the following 2 factors
are important: (a) followability, which means increasing
the flow rate of aspiration, and (b) holdability, which means
increasing the vacuum to the maximum and decreasing the
power of the U/S emissions. If you are using a peristaltic
pump, the vacuum should be kept at a high level during
this entire step, but if there are adhesions in the groove, you
will never create a vacuum. Following the fracture, the flow
rate is increased to allow the fragments to be carried toward
the U/S tip. If instead you are using a Venturi pump, the
vacuum passes from a low level at the groove incision stage
to a higher level during quadrant removal so as to allow
the fragments to be brought more easily to the phaco tip.
As these 4 quadrants are but a part of the endonucleus, it is
clear that the first quadrant that has to be removed might
be a little trapped in position and therefore more difficult
to extract and isolate.
Start with the smallest of the quadrants and with the
use of a spatula to put in an endonuclear crack and then
under 1 of the quadrants that you can lift using a viscoelas-
tic substance (also recommended because it facilitates the
maneuver) that will fill the space between the epinucleus
and the bottom of quadrant and act as a cushion. Lift the
tops of the quadrants to make them more accessible to the
phaco tip while depressing the rounded peripheral part. By
using the dynamics of suitable fluids, appropriate phaco
tips, and instruments for maneuvering the nucleus, each
quadrant can be occluded in sequence and safely be brought
to the safer central area. Emulsification is made easier using
pulsed bursts of U/S. Remember to preserve the epinuclear
cortex to maintain the cushion effect of the concentric
separation.
The key to removing the epinuclear cataract is mobility
(ie, proper hydrodissection). If you have difficulty in mobi-
lizing the epinucleus, it is best to stop and carry out a new,
more effective hydrodissection that will be easier as the
endonucleus has been removed but nonetheless can be done
as long as the capsular bag maintains its continuity. In other
words, as long as the capsulorrhexis and posterior capsule
are intact. With the removal of the endonucleus, the epinu-
cleus looks like a dish and is removed by lowering the ring
of the dish. There you need to approach the central inferior
ring of the epinucleus with the phaco tip, keeping the pedal

in position 2 (aspiration). Once engaged, pull the epinucleus
very slowly toward the center, then break the fragment of
the ring and remove it, keeping the pedal in position 2 or
using short bursts of low-power U/S. The dish is then rotat-
ed and the capture/removal maneuver is repeated until
almost half of the ring has been removed. At this stage, try
to engage and turn the remaining epinucleus upside down
so as to facilitate the removal of not only the remaining
ring but also the central epinucleus. This is done by grasp-
ing the epinuclear ring in, more or less, the inferior-central
position, keeping the pedal in position 2 and gently pulling
toward the center. At the same time, the second instrument
is placed at the top of the central, or epinuclear, plane and
is used to give it a gentle tap from below. This maneuver
“curls” the epinucleus around the inferior capsular fornix
without actually nearing the capsule periphery. This is the
“flip” of Fine’s “chip-and-flip” technique.
As with all endolenticular maneuvers, this process
should be performed with the minimum of force. If the
Endocapsular Techniques  49
epinucleus resists the flip, it is probably too thick, so rather
than force the maneuver, the surgeon should remove part of
the ring and try again.
At this stage, the remaining epinucleus is totally free and
takes up the central part of the bag. Using aspiration alone
(with occasional gentle linear pulsed burst from the phaco
tip at low power), the epinucleus too is removed. During
this maneuver, it is wise to place the second instrument
between the posterior capsule that is no longer protected
and the phaco tip so as to create a physical barrier to pre-
vent any contact that might take place due to a sudden
involuntary movement forward of the posterior capsule.
There are different variations of the “divide and con-
quer” technique. There is splitting into 2, then 4 or frac-
tional 2/4 proposed by Dillman–Maloney, Trench DNC,
and Gimbel’s Crater DNC, as well as the technique of frac-
turing the nucleus into 4 quadrants as proposed by Buratto
(Table 3-7).
50  Chapter 3

TABLE 3-7.
FOUR-QUADRANT NUCLEOFRACTURE—BURATTO S TECHNIQUE
Phacoemulsification
Phacoemulsification̶First Phase: Capsulorrhexis and Hydrodissection Executed
Shaving and ● Vacuum 10; flow 10 to 15; U/S 70% to 80% with 30-degree tip
creation of the ● Removal of cortical material and epinucleus inside the borders of capsulorrhexis
first semigroove
● Start just over the proximal edge of capsulorrhexis and stop just before the distal edge
● Without occlusion, create a groove with width 1.5 times the diameter of the sleeve
● Depth: same diameter as the sleeve
● Enter with the spatula through the side incision
● Rotate the nucleus by 90 degrees
● Create another semigroove as described above
● Extend the first semigroove. The second part of the groove must be slightly deeper
than the first
● Extend the second semigroove as described above. Proceed in the same way with
every other groove until you reach a good depth
● Deepen the central part of the first semigroove (remember that the depth of the
nucleus is higher in the middle and lower distally, where the tip sinks more, so be
careful)
● Rotation of the nucleus with the spatula
● Deepen the second semigroove as described above. Proceed in the same way with
every other groove until you reach a good depth
Observe the ● Check if the groove is deep enough in the center and if it follows the theoretical curve
situation of the posterior capsule
● The reflex coming from the bottom must be sufficiently red (very obvious reflex:
groove is too deep, barely visible reflex: groove is superficial)
Phacoemulsification̶Second Phase
Nucleofracture ● Insert the spatula through the side port incision and position it just beyond half the
phase 2 depth of the groove
● Position the tip at the same level on the other side of the groove
● Open irrigation or open irrigation and aspiration
● Draw the 2 instruments apart until the nucleus separates from 6 o clock to just beyond
the center of the groove
● Rotate the nucleus by 90 degrees and repeat the maneuver
● Rotate the nucleus by 90 degrees again and repeat the maneuver
● Rotate again and repeat the maneuver
● The nucleus is now divided into 4. If in doubt, repeat a full turn and check the fracture
extends into the deepest portions of the nucleus
(continued)
 Endocapsular Techniques  51

TABLE 3-7. (continued)

FOUR-QUADRANT NUCLEOFRACTURE—BURATTO S TECHNIQUE
Phacoemulsification̶Third Phase
Capture and ● The parameters are changed: vacuum 80 to 180, depending on the hardness of the
removal of nucleus; flow 12 to 18 depending on the hardness of the nucleus; U/S 50% to 70%,
quadrants linear; the harder the nucleus, the higher the vacuum and flow needed
● Apply the spatula in the superior part and lift the inferior vertex of the quadrant
● Create contact with the U/S tip. If there is a chance occlusion occurs, wait. If the
nucleus is hard and rough-edged and occlusion does not occur, proceed with a mild
discharge of U/S power to create a thin groove that makes occlusion easier
● Once occlusion occurs, wait for the vacuum to reach the preset levels
● Then pull the sector toward the center
● Next, emulsify it with short discharges of U/S power, keeping it under control with
the spatula
● Repeat the procedure with the other quadrants
Removing the ● Mobilize the epinucleus with the U/S tip and the spatula
epinucleus ● The epinucleus must occlude so it can be removed with aspiration and/or brief
discharges of U/S power
● Parameters: vacuum 50 to 80; flow 15 to 48; U/S power 30% to 40%, linear
Bimanual ● 2 separate cannulas are used̶1 for aspiration and 1 for irrigation
aspiration of ● Parameters: vacuum 350 to 400, flow 20, aspiration tip with 0.3 orifice, bottle very high
cortical material
● The irrigation cannula is inserted through 1 of the service incisions and the aspiration
cannula is introduced through the other one
● Whereas the irrigation cannula is kept just inside the incision, the aspiration cannula is
introduced into the bag and made to touch a portion of the cortical material without
activating aspiration
● The pedal to activate aspiration is then pressed and the frustum occludes the tip
● When the vacuum is high enough the frustum is detached and brought into the
middle of the capsular bag
● At this point the pedal is pressed further to increase the vacuum. The material is
gradually removed
● The procedure is repeated the number of times required to remove the cortical
material in a semisac
● The 2 cannulas are inverted and the cortical material is removed from the other
semisac
Preparation of ● The capsular bag is filled with Provisc (because it inflates the bag better and is easier to
the sac and the remove)
anterior chamber ● The anterior chamber is shaped with Viscoat (because it is better at protecting the
endothelium during intraocular lens (IOL) pressure and its incomplete removal does
not have damaging effects on the ocular tone)

REFERENCES
1. Koplin RS, Anderson JE, Seedor JA, Ritterband DC. In situ nucle-
ar disassembly: efficient phacoemulsification without nuclear
rotation using lateral sweep sculpting and in situ cracking tech-
niques. J Cataract Refract Surg. 2009;35:1487-1491.
2. Fine IH, Maloney WF, Dillman DM. Crack and flip phacoemulsi-
fication technique. J Cataract Refract Surg. 1993;19:797-802.
3. Gimbel HV. Trough and crater divide and conquer nucleofractis
technique. Eur J Implant Refract Surg. 1991;3:123-126.
4. Gimbel HV. Divide and conquer nucleofractis phacoemulsifica-
tion. J Cataract Refract Surg. 1991;17.281-291.
52  Chapter 3

5. Shepherd JR. In situ fracture. J Cataract Refract Surg.
1990;16:436-440.
6. Blumenthal M, Assia E, Neuman D. Lens anatomical principles
and their tecnica implications in cataract surgery: II. The lens
nucleus. J Cataract Refract Surg. 1991;17:211-217.
7. Fine IH. The chip and flip phacoemulsification technique.
J Cataract Refract Surg. 1991;17:366-371.
8. Fine IH. The Chip and Flip Phacoemulsification Technique.
SLACK Incorporated; 1992:3-23.

Phaco Chop Technique
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
All chopping techniques are based on the principle of
“breaking” the lens into smaller, more maneuverable pieces.
The advantage of this is the ability to remove a 10-mm
nucleus through a 5-mm capsulorrhexis and the possibility
of emulsifying most of the lens at the center of the pupil at
a safe distance from posterior capsule.
The phaco chop was developed by Kunihiro Nagahara1
in 1993 and is the most recent nuclear fracturing technique
that uses the lamellar structures of the nucleus to create
radial fractures in the lens. Since it was first performed,
variations based on chopping have been developed and
these can be divided into 2 categories: horizontal and verti-
cal chopping.
Both techniques share the same benefits as manual
fragmentation of the nucleus but achieve the objective in
a different way. The classic Nagahara technique exempli-
fies horizontal chopping as the tip moves horizontally
during the separation while the second instrument moves
along the vertical plane to create the fracture. In reality, it
is compression that fractures the nucleus. It exploits the
natural fracture lines created by the orientation of the len-
ticular fibers. The first step is to engage the nuclear equa-
tor inside the epinuclear space with the chopper, and then
pull it to the phaco tip, near which it is then turned to face
horizontally. The key to this is the cut and the depth of the
chopper (modified lens hook), whereas sufficient phaco tip
depth is the crucial factor in the vertical chop technique, in
which the chopper is used as a cutter that slices the nucleus
anteriorly, from top to bottom, where it is engaged by the
phaco tip. Horizontal chopping is more advantageous in
eyes with a deep anterior chamber, and in cases of sublux-
ation or traumatic cataracts, as it creates decreased mobil-
ity and inclination of the nucleus and provides subdivision
into smaller, more mobile fragments. Its limitation is the
- 53 -
4
inability to section brunescent or thick nuclei and the fact
that it cannot be used in the absence of an epinuclear shell,
as there is not enough room to place the chopper. Vertical
chopping is useful in these cases, as it can fracture the
tough posterior plane as the chopper makes the fracture
vertically toward the bottom while the horizontal vector
pushes the nucleus against the tip. There is also “diagonal”
chopping, which combines the mechanical advantages of
both strategies. This is a variation of the vertical chop that
is used in the presence of brunescent lenses, as it combines
the action of the horizontal vector that pushes the nucleus
against the tip and the vertical vector that initiates the frac-
ture toward the bottom.
Phaco chop is thus a surgical technique in which the
nucleus is split from the periphery toward the center. It
does not require central sculpting and, generally speak-
ing, aspiration is followed by emulsification. The initial
aspiration, that is, the removal of soft material, simplifies
the procedure, as it allows the hardness of the nucleus to
be evaluated better, improves visibility, and, therefore, lets
the surgeon know where and when to insert the phaco tip.
It also provides a better working plane, in the sense that the
chopper can be introduced more safely as the nucleus and
its equator are more clearly visible.
NAGAHARA S PHACO CHOP
TECHNIQUE OR NUCLEAR CRACKING
The author adapted the same principle as used for split-
ting wood by developing a tool (the ax) for fragmenting the
nucleus (the log) by placing it against the phaco tip (the
stump). This allowed the nucleus to be fragmented along its
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 53-71).
© 2014 SLACK Incorporated.
54  Chapter 4
A B
Figure 4-1. (A) Horizontal chop (side view). (B) Second stage of horizontal chop (view from below).
longitudinal fibers using opposing force instead of the par-
allel force used by Gimbel 7 years earlier. A round log can
be split in less time and with less force if the ax slices along
the grain. Every movement attracts the nucleus toward the
center of the capsular bag away from the fornix.
Nagahara performed this technique by performing the
capsulorrhexis and hydrodissection, then entering the eye
with the phaco tip that, after having removed part of the
superficial cortex and the epinucleus, is used to pierce the
central portion of the nucleus as near as possible to the
entrance to the chamber. Using a short burst of ultrasound
(U/S), the tip is lodged in the nuclear material. It must
penetrate deeply toward the center of the nucleus and must
also be stabilized to allow the chopper to make a good split.
Once the nucleus has been “impaled,” it is maneuvered
slightly to the right and left to assess its state of attraction
to the U/S tip, or the state of occlusion. If the phaco tip does
not engage the nucleus, it is because there is insufficient
aspiration, the nucleus is too soft, the tip is too angled,
or simply because the tip is incorrectly positioned against
the center of the nucleus. Aspiration is used to bring the
nucleus slightly closer to the incision and to keep it still so
that the chopper, which is introduced through the side port,
can be positioned opposite the incision below the anterior
capsule as peripherally and as deeply as possible to reach
the nuclear equator. While the phaco tip keeps the nucleus
steady, the chopper is moved toward the U/S tip so as to
fracture the nucleus; when the second instrument nears the
phaco tip, both are gently moved in a lateral direction. The
chopper goes to the left and the tip to the right, efficiently
fracturing the nucleus into 2 parts. It is important that the
phaco tip is always as parallel as possible to the iris plane
throughout the whole procedure so as to avoid any risks of
burns and therefore poor wound sealing. The procedure
involves no sculpting and the nucleus is fractured into
2 distinct parts in just a few seconds (Figure 4-1).
The next step is to rotate the nucleus about 90 degrees so
that the fracture line faces horizontally. The process is then
repeated on the bottom half of the nucleus. The first “blow”
is the most important and the most difficult, just as in split-
ting logs where the positions of the ax, the log, and the sup-
porting tree stump are vital, the same applies, in that the
phaco tip and the chopper must be in exactly the right posi-
tion to “attack” the nucleus. The U/S tip must be at the most
dense part of the nucleus so that it has the maximum sup-
port, whereas the chopper must be near the posterior part
beyond the lens equator. The harder the nucleus, the greater
the number of small nuclear segments needed so that they
can be extracted from the capsular bag with ease to then
be emulsified with quick bursts of U/S. The most delicate
moments are when the nucleus, even though fractured, is
still inside the capsular bag and then has to be manipulated
for subsequent cracking, and when the first quadrant, being
held in place by the adjacent quadrants, has to be removed.
In reality, the presence of numerous segments increases
the volume inside the bag and decreases mobility. To sim-
plify the procedure, it is better to remove the first fractured
piece or at least a small nuclear segment immediately. This
provides a better shaped bag and, at the same time, offers
sufficient room to position the nucleus better for the steps
that follow (Figures 4-2 and 4-3).
To summarize, the advantages of this technique are as
follows:
● Decrease in phacoemulsification energy with less dam-
age to the endothelium and a lower risk of wound burns
● U/S used over shorter times and therefore shorter
procedures
● Less stress for zonules and capsular bag areas
● Option of performing supracapsular emulsification
● Freedom from the red reflex
● Option of more easily emulsifying hard/brunescent
nuclei
● Option of using aspiration first followed by
emulsification
 Phaco Chop Technique  55

A B

C D

Figure 4-2. Phaco chop. (A) After having shaved the cortical material in the central portion, the U/S tip is inserted deeply into the
center of the nuclear material going into occlusion. Then the chopper is inserted under the capsulorrhexis holding it horizontally
and then vertically. (B) The 2 instruments are then moved away while the chopper comes closer to the U/S tip, resulting in splitting
of the nuclear material. (C) Keeping the nucleus very still with the U/S tip, the chopper is advanced toward the tip separating the
cortical material along its path. (D) When the 2 instruments are about to come into contact they are separated in order to obtain a
deep split by pushing the U/S tip to the right and the chopper to the left. (continued)
56  Chapter 4

E F

G H

Figure 4-2. (continued) (E) Once the first piece of material is grasped, it is moved to a safe site, keeping it tightly attached to the
phaco tip with occlusion and then emulsified. (F) The nuclear material is rotated in order to distally expose a hard portion suitable
for occlusion. (G) Occlusion is attempted and then the separation maneuver is repeated in the adjacent nuclear portion. (H) The
nucleus is rotated 30/40 degrees with the assistance of the chopper. (continued)
 Phaco Chop Technique  57

I J

Figure 4-2. (continued) (I) New occlusion, and fracture with the chopper. (J) Using occlusion and the chopper, we obtain another
piece of material.

A B

Figure 4-3. (A–C) Horizontal chop. It exploits the same benefits as manual nucleus fragmentation. The tip moves on the horizontal
plane during separation while the second instrument moves along the vertical plane to create the fracture. In reality it is compres-
sion that fractures the nucleus. It exploits the natural fracture planes created by the orientation of the lenticular fibers. The first
step is to capture the nuclear equator inside the epinuclear space with the chopper, then direct it to the phaco tip nearby. It is then
turned to face horizontally. The key to this is the cut and depth of the chopper (modified lens hook). Horizontal chopping is more
advantageous in eyes with a deep anterior chamber, and in cases of subluxation or traumatic cataracts. Its limitation is the inability
to section brunescent or thick nuclei and the fact that it cannot be used in the absence of an epinuclear shell, as there is not enough
room to accommodate the chopper. (continued)
58  Chapter 4

C A

Figure 4-3. (A–C) (continued)

B
● The key role played by the second instrument (as
opposed to the phaco tip that remains relatively sta-
tionary at the center of the pupil): The chopper pro-
vides great maneuverability and freedom of movement
that is useful if the nucleus poorly rotates for any
reason (poor hydrodissection, excessive zonular weak-
ness, etc) (Figure 4-4).
These considerations make phaco chop the best tech-
nique for complicated cases, such as brunescent or white
cataracts, with zonular weakness, posterior polar, and cases
of tears in the capsulorrhexis, or small pupils. Like all other
techniques, however, it has its problems: (1) penetration
of the chopper below the capsule; (2) the approach of the
chopper to the phaco tip; (3) the rupture of the nucleus as
deep as the posterior capsule due to the risk of tears in the
capsulorrhexis and the posterior capsule; (4) the extraction
of the first piece and its subluxation from the equator of the
bag to the center of the anterior chamber; (5) performing
the whole surgery with a high level of vacuum; and (6) the Figure 4-4. (A and B) Vertical chop. The chopper is used as a cut-
ter that slices the nucleus anteriorly, from top to bottom, where
presence of pieces of nucleus floating around the chamber.
it is stuck to the phaco tip. The crucial factor is adequate phaco
There are differences between nucleus fracturing into tip depth. Vertical chopping is indicated for hard nuclei, as it
4 quadrants and phaco chop: in the former, the vacuum is can fracture the tough posterior plane as the chopper makes
only used at the end of the procedure to extract the quad- the fracture vertically toward the bottom while the horizontal
rants, the 2 instruments, separate or crack the 2 heminuclei, vector pushes the nucleus against the tip.
the fracture occurs at the center as opposed to at the equa-
tor, central sculpting is needed that takes time and energy,
the grooves create space and therefore allow the various and emulsification almost always takes place under aspira-
pieces to split away from each other easily and to be mobi- tion (and therefore with less use of U/S in shorter time),
lized with ease, and the division takes place using the phaco there is no creation of space to mobilize the sectors, and the
tip just like any spatula. Compared to this, in phaco chop, phaco tip plays an active mechanical role, in that it serves
a high level of vacuum has to be used throughout. Nuclear to create a break through occlusion.
division takes place mainly in a centripetal radial direction

DIFFERENCES BETWEEN PHACO CHOP AND FOUR-QUADRANT NUCLEOFRACTURE
Phaco Chop
● High vacuum is required throughout the
operation
● The nucleus is divided using the 2 instruments,
but division is mainly centripetal, radial, and
without the creation of grooves
● Division is from the equator toward the center
● Emulsification occurs always (or almost) via
occlusion (ie, with aspiration; U/S is used less and
for shorter periods)
● No room is made for mobilizing sectors
● In the chop, a high vacuum (ie occlusion) is
used to create a break̶the tip has an active
mechanical function and is not used just for
emulsification
Both these techniques have their limitations that can be
overcome, however, by a combination of their individual
features. In other words, starting with 1 technique, stop-
ping, and then continuing with another to have the so-
called stop-and-chop technique.
THE STOP-AND-CHOP TECHNIQUE
This innovative, hybrid technique was proposed by Paul
Koch and borrows, then combines, techniques developed
for other applications. From Gimbel’s “divide and conquer”
technique derives the concept of creating space in the cen-
ter of the nucleus before fracturing the periphery; from
Nagahara’s phaco chop comes a modified simple tool for
fracturing the nuclear ring. In addition, the strategy from
this technique can be used not just in eyes with dilated
pupils but also in those in which the pupils are small. The
nucleus is sculpted in line with the principles originally
described by Gimbel, creating a groove in soft cataracts or
a crater in hard ones as if it were a Shepherd-type cross-
nuclear fracture. It is important to create a space in the
middle of the nucleus so as to have room to manipulate the
nuclear fragments inside the capsular bag and to stop them
being brought into the anterior chamber. At the same time,
the amount of sculpted material must be limited, as the ease
with which the nucleus is manipulated depends on preserv-
ing the hardest central portion. If you make a crater, it is
Phaco Chop Technique  59
Four-Quadrant Nucleofracture
● Low parameters are used at the beginning, high
parameters at the end after division is obtained
● High vacuum is used to extract pieces from the
equator
● The 2 instruments are used to separate (ie, to
move the 2 seminuclei apart)
● Fracture is from the center to the equator
● The central sculpting implies emulsification
without (or with little) aspiration (ie, without
occlusion, which causes energy dispersion and
wasted time)
● The grooves create room, which allows the
various pieces to detach easily from one another
and to be easily mobilized
● The U/S tip is not used in division, which is
performed using the U/S tip as an ordinary spatula
recommended to create just 1 groove in the center in order
to form a line of lower resistance to subsequent fracturing
moves. The next step consists of splitting the nucleus into
2 halves with the help of the chopper, which is introduced
from the side port as in the standard nuclear fracture
procedure. Once the nuclear fracture has been completed
using a groove or crater, stop and continue with the phaco
chop technique. The subsequent steps engage the phaco
tip into the nuclear material, plunge the chopper in, break,
separate, and remove. The nucleus is rotated by 90 degrees
to allow the phaco tip to attach to the lower half of the
nucleus (equidistant from the right and left extremities),
return from emulsification aspiration mode (position 2),
and occlude the nucleus. You then place the chopper into
the peripheral portion of the nucleus and draw it toward the
phaco tip, making a deep cut. As the 2 instruments gradu-
ally approach each other, separate them, pushing the phaco
tip and the nuclear fragment to the right and the chopper
and what remains of the nuclear material to the left. The
nuclear fragment that is now on the phaco tip, and is held
in place by the same aspiration used to occlude it, is now
ready for emulsification, if it is small. If it is too big, it can
still be further chopped into smaller pieces while on the tip.
These smaller pieces can be easily emulsified without need-
ing much manipulation and without having to be searched,
captured, and rotated. Rotate the nucleus by 180 degrees to
bring the other half to the lower part of the capsular bag,
then repeat all these steps so that a strategic nuclear collapse
60  Chapter 4

takes place. This technique provides excellent stability of
the nucleus as, unlike other endocapsular techniques, the
chopper plays an active, determinant role. The 2-handed
action is used during the whole procedure and is a constant
factor in the stages of nucleofracture and in the removal of
nuclear sectors. The surgeon must focus his or her atten-
tion on controlling both the chopper and the phaco tip at
all times. A typical cataract of medium density involves the
2 halves being split into 3 parts, whereas a hard cataract is
split into 1 piece more and a soft one into 1 less. During the
whole procedure, no nuclear segment is raised or turned
upside down; the nucleus is just rotated. This type of proce-
dure features the advantages of the Gimbel and Nagahara
techniques. It prepares the nucleus for fragmentation of
the ring, creates space in the center of the nucleus for the
manipulation of fragments, and breaks the nucleus with
a simple appositional chopping movement. It also avoids
problems seen in the other 2 techniques: movements toward
the exterior of the original fracture and the reduced space
for manipulation that is inherent with the chop technique
alone. This also allows the stop-and-chop technique to be
used with ease in cases of small pupils.
Thanks to nucleofracture techniques, it is possible to
deal with very hard nuclei without having to resort to high
power requiring long U/S time: this results in less surgical
trauma, improved postoperative comfort, and faster patient
recovery times. Throughout the procedure, apart from the
energy transmitted to the nucleus that is free from con-
nections with the epinucleus and the cortex, no energy is
transmitted to the posterior capsule or the zonular area
because of the buffering action afforded by the external
cortex and the separation created by the hydrodissection
process (Figures 4-5 and 4-6).

STOP-AND-CHOP—BURATTO S TECHNIQUE
Preamble The pure chopping technique according to Nagahara is a difficult technique that must be
learned in stages
The stop-and-chop technique is a simple procedure that must be learned before advancing
to pure phaco chopping
First part ● Parameters: 15-degree tip, vacuum 10; flow 18; U/S 70%
● A semigroove is created, crossing the nucleus with a proximal‒distal direction, and
completed after a 180-degree rotation
● Depth of the groove: more than half the thickness of the nucleus. Width: wider than the
diameter of the sleeve
● Using the chopper and the U/S tip, the nucleus is broken into 2 separate pieces. It
is important that they are completely separate, so that when, in the next phase, the
chopper divides the seminucleus into pieces, the fragments will be free immediately
(ie, not attached to the remaining material in any way)
Second part ● The groove is positioned transversally (ie perpendicularly) to the U/S tip, in a position that
is comfortable to try for and obtain occlusion easily
● The parameters are changed. Vacuum 200 to 250; flow 18; U/S power 50%
● Achieve occlusion, then let the vacuum rise. In the case of insufficient occlusion, it can be
improved via a brief discharge of U/S power
● Next, the chopper passes underneath capsulorrhexis and reaches the equator. It creates a
first wedge, about 1/8 to 1/6 of the nucleus or simply 1/4 (half seminucleus)
● The wedge is easily released because the division line is at the center. It is easily mobilized,
partly because by creating the groove room is made in the nucleus
● The first sector obtained is captured via occlusion and moved to the center of
capsulorrhexis. If small, it can be emulsified; otherwise, it is divided in 2 with the chopper
● The same procedure is applied to the second quadrant
● The second seminucleus is positioned distally. It is captured via occlusion, divided, and
fragmented
 Phaco Chop Technique  61

A B

C D

Figure 4-5. Stop-and-chop. (A) A groove is created in the center of the nucleus toward its periphery. (B) The nucleus is rotated
180 degrees and the groove completed. The groove depth must reach at least half of the nuclear thickness. (C) The nucleus is
rotated 90 degrees in order to position the groove perpendicularly to the U/S tip. (D) Then, using the chopper, a portion of material
is detached from the heminucleus and emulsified. (continued)
62  Chapter 4

E F

G H

Figure 4-5. (continued) (E) The U/S tip is placed in the groove and occlusion started. The chopper is inserted under the capsulor-
rhexis holding it horizontally and then, in the proximity of the equator, placed vertically and pulled toward the tip, then moved
to the left in order to obtain a sector of nuclear material. The material is dragged to the center and fragmented using occlusion.
(F) After various divisions, only the last fragment of the first heminucleus is left to be emulsified. (G) The second heminucleus is
positioned distally and treated like the first one. (H) The procedure is repeated until the last sector is removed.

a number of surgeons: Neuhann in Germany, Vasavada in

QUICK CHOP TECHNIQUE
Since Nagahara introduced the traditional “phaco chop,”
a number of variations of the technique have been devel-
oped. One of them appears to stand out in terms of greater
safety and efficiency: the Dillman “Quick Chop” technique.
Actually, this technique was described simultaneously by
India, Pfiefer in Slovenja, and Fukasaku in Japan presented
a similar variant called “snap and split.” The element com-
mon to all of these techniques is the position of the chopper;
it is pressed against the anterior surface of the nucleus, in
front of, or to the side of, the phaco tip used to immobilize,
instead of being used in a position external to the equator of
 Phaco Chop Technique  63

A B

C D

E F

Figure 4-6. Stop-and-chop. (A) Creation of a groove. (B) Division of the nucleus into 2 parts. (C) Rotation of the 2 heminuclei, occlu-
sion of the distal heminucleus, and division of the material with the chopper. (D) Further rotation of the material and occlusion of
the second heminucleus. (E) Emulsification of nuclear fragments. (F) Removal of the last nucleus fragment.

the lens. This technique became popular among surgeons
who considered the phaco chop to be problematic and
potentially dangerous, particularly when the position of the
chopper, external to the edge and beyond the anterior cap-
sule, obstructs vision. The subtle elegance of the quick chop
allows an efficient division of nuclei of soft, medium, and
extremely high density. The surgeon can work more com-
fortably even with small pupils and a small capsulorrhexis.
The amount of carving necessary for the central groove is
restricted to the direct penetration of the phaco tip in the
superocentral portion of the nucleus, thanks to short and
intense U/S pulses.
Splitting the nucleus into 2 portions is facilitated, and
the potential damage to the integrity of the capsule is
avoided when the chopper slides underneath the anterior
capsule as far as the nucleus to split it into 2 halves.
Following capsulorrhexis and the removal of the ante-
rior cortex, the phaco tip is pushed deep into the center
of the nucleus at an optimal angle of 30 degrees with a
U/S burst. The tip must penetrate to more than half of the
central nuclear thickness. This is increasingly important
when the nucleus is harder. When the nucleus is separated
into 2 heminuclei, and then into quadrants, there may be
very strong posterior attachments. These may prevent the
successive mobilization of the pieces and the formation of a
bowl that is very difficult to manage. To avoid this problem,
the surgeon must pay attention to the relationship between
the U/S tip and the sleeve: the greater tip exposure has the
64  Chapter 4
dual objective of freer penetration in the nuclear substance
and the exact visualization of the depth in the area closer
to the posterior capsule. At this point, the chopper is posi-
tioned right in front of the mouth of the phaco, inside the
area of the rhexis, clearly visible to the surgeon, but pen-
etrated as deeply as possible. The surgeon pulls sideways
and downward with the chopper, pulling the phaco tip
upward in the other direction to separate the nucleus into
2 pieces. The 2 halves of the nucleus are rotated through 90
and 180 degrees and the procedure is repeated to create the
4 quadrants. The 4 pieces of the nucleus are emulsified 1-by-
1 using short bursts of U/S (pulse is preferable). The surgeon
uses the chopper to fragment the pieces that have been
presented to the phaco tip-an action that predominates over
phacoemulsification itself.
This is clearly the elective technique with a small pupil
because the maneuvers are performed exclusively at the
center of the pupil and the capsular bag, and at a safe dis-
tance from the endothelium and the posterior capsule.
If it proves difficult to separate the pieces, the surgeon
may decide to inject Visco Elastic Substance (VES) to raise
and free the pieces from each other and the posterior cham-
ber with the formation of a protective cushion toward the
posterior chamber.
OTHER TECHNIQUES DEVELOPED
AFTER THE PHACO CHOP
1. Bevel-Down Phaco Chop (Phaco Drill): This tech-
nique differs from the traditional phaco chop in that
the U/S tip is used in the bevel-down position to
produce a larger contact surface between the tip and
the nuclear material to be emulsified. This results
in a larger occlusion area, consequently improved
holdability, and greater exploitation of the U/S. This
approach minimizes the unnecessary dissipation of
energy caused by the insufficient contact between the
phaco tip and the nucleus.
2. Choo-Choo Chop-and-Flip Phacoemulsification:
This is the last technique that developed from the orig-
inal technique described by Howard Fine. The name
derives from the sound produced during phacoemul-
sification (in burst mode) that Fine used to impale the
nucleus. This technique involves both hydrodissection
and hydrodelamination to separate the nucleus from
the epinucleus. Fine–Nagahara’s chopper is positioned
at the center of the anterior surface of the endonucleus
(once the cortex has been aspired) and is allowed to
slide inside the golden ring. While the chopper stabi-
lizes the endonucleus, the phaco tip impales the nucle-
us. The use of the burst, or pulse mode, reduces the
cavitation energy required, producing tighter adhesion
and consequently greater holdability. The successive
chopping maneuvers differ from the original phaco
chop technique because they are performed inside the
soft epinuclear material. Once the endonuclear mate-
rial has been completely removed, the epinucleus is
removed using the flip maneuver.
Prechop Technique
Takayuki Akaoshi and Jochen Kammam were the pio-
neers of prechopping the nucleus before inserting and using
the phaco tip. It was intended for hard nuclei (brunescent,
mature) with the aim of shortening U/S times and reducing
thermal and mechanical damage to the endothelium. This
technique is based on analysis of the anatomy of the lens,
its possible lines of division and, originally, was performed
one-handedly. Specially designed surgical cracking impal-
ing instruments with crossed points and slender arms have
pointed tips to penetrate the core of the nucleus more easily.
In order to provide better visibility and stability in the
chamber, after capsulorrhexis and additional injection of
viscoelastic substance, the nucleofracture instrument is
inserted deeply and progressively into the central portion
of the nucleus at a constant entry angle of 30 degrees. The
next step is to open the blades slowly to create a full-depth
fracture. Once the nucleus has been rotated 90 degrees, the
cracking maneuver is repeated and is followed by phaco-
emulsification: apart from reducing U/S time, this tech-
nique decreases the stress on the zonules and creates less
tilting of the nucleus. The disadvantages of this technique
are the difficulty of introducing the blades without creating
traction and poor visibility after the initial cracking since
lenticular debris released by the this maneuver is not imme-
diately aspirated by the phaco tip. In addition, the blades
were designed to create 4 quadrants, and this is not ade-
quate for hard and bulky nuclei where the creation of many
small pieces is desired. In effect, with brunescent cataracts,
it is difficult to determine the depth of penetration of the
instruments used for the cracking. Increased depth of pen-
etration risks rupturing the capsule. One last consideration
is that prechopping calls for 1 step and 1 instrument more
than needed in the chop technique. This technique is use-
ful after the division into sectors has been done with Femto
cataract surgery (Figure 4-7).
Below is a summary of the phacofragmentation
techniques:
● Non-nucleus fracturing techniques, are those in which
the emulsification maneuvers take place completely
inside the bag and the second instrument only helps to
stabilize, rotate, and tilt the nucleus. The endonucleus
is sculpted with considerable use of U/S and there
are no 2-handed mechanical movements used during
fragmentation. These techniques can be used for soft
cataracts and posterior subcapsular or anterior cortical
cataracts. In these cases, the chip-and-flip technique is
also suitable.
 Phaco Chop Technique  65

A B

C D

Figure 4-7. Prechop technique. (A) Specially designed surgical cracking forceps with crossed points and slender arms have pointed
tips to penetrate the core of the nucleus more easily. After capsulorrhexis and viscoelastic injection, the forceps to fracture the
nucleus are inserted deeply and progressively into the central portion of the nucleus, maintaining a 30-degree entrance angle in
order to guarantee perfect visibility and chamber stability. (B) The prechopper is brought toward the central part of the nucleus. (C)
The crossed arms are slowly opened to create a deep fracture. (D) The prechopper is then lifted, rotated, and made to the full depth.
The prechopper should not be deepened too much. (continued)
66  Chapter 4

G
H

Figure 4-7. (continued) (E) Then the nucleus is rotated 90 degrees and the cracking maneuver is repeated. (F) Progression of the
prechopper toward the center of the nucleus and opening of its blades. (G) The crossed arms are slowly opened to create a com-
plete fracture. (H) After rotating the nucleus 90 degrees, the cracking maneuver is repeated. Rotate the prechopper if necessary.
(continued)

I J
● Mixed techniques such as Gimbel’s “divide and con-
quer” and Shepherd’s cross technique allow the remov-
al of very hard nuclei, using less U/S power over shorter
times. They work well with medium cataracts (eg, ante-
rior cortical, advanced anterior and posterior cortical,
medium corticonuclear, and medium-density nuclei).
● Pure nucleofracture techniques (invented by Gimbel,
Fine, and Maloney) are ideal for Nagahara’s phaco
chop: the nucleus is fractured mechanically at the
start of the procedure with the chopper—an auxiliary
instrument that no longer plays a support role but is
used to mechanically cut the nucleus. One advantage
is that you can work with a minimal amount of U/S
using mainly occlusion with high degrees of vacuum.
Intended for medium hard nuclei, advanced cortico-
nuclear, advanced nuclear, and brunescent cataracts
(Figures 4-8 and 4-9).
CHOOSING SURGICAL TECHNIQUES IN
RELATION TO CATARACT TYPE
As mentioned earlier, each technique has different
characteristics that must be clearly understood, based on
surgical experience for each type of cataract. The right
mental attitude is (a) to assess in a preoperative setting the
type of opacity while keeping the patient’s history in mind
(possible previous trauma or other problems, concomitant
glaucoma, high degree of myopia or pseudoexfoliation
syndrome, etc) and (b) to identify the first choice technique
and to be ready to modify it during the procedure should
Phaco Chop Technique  67
Figure 4-7. (continued) Prechop technique. (I) The prechopper
should not go too deep into the nuclear material. (J) The nucleus
is correctly divided into 4 sectors.
unexpected differences or difficulties arise. The technique
can be modified to deal with the hardness of nuclei.
There are several different cataract classifications that
are used to define the hardness of the nucleus, one of the
most widely used is the following:
● Grade 1: Cortical or subcapsular cataract: this cataract
is pale gray with a very obvious red reflex and requires
minimal U/S use.
● Grade 2: Subcapsular cataract with nuclear sclerosis: a
yellowish-gray cataract with a very obvious red reflex.
It requires reduced U/S use.
● Grade 3: A nuclear or corticonuclear cataract: this cata-
ract has a yellowish color, the red reflex is good, and
there is moderate use of U/S.
● Grade 4: A dense nuclear cataract: it is an amber color,
the red reflex is reduced and it requires prolonged use
of U/S.
● Grade 5: A completely dense cataract: it is dark brown
in color, the red reflex is absent and it requires
extremely prolonged use of the U/S.
The Grade 1 cataract (or a cataract with a soft nucleus)
is normally seen in young patients affected by congenital or
juvenile cataract, or in patients who undergo cataract sur-
gery for refractive purposes. The soft nucleus necessitates
a different technical approach with respect to the standard
phaco. The poor resistance of the material prevents or
limits the possibility of resorting to nuclear manipula-
tion maneuvers. In young patients, the capsule is highly
elastic and the capsulorrhexis will tend to be larger than
expected by the end of the procedure: this must be taken
68  Chapter 4

A B

C
D

Figure 4-8. Prechop technique. (A) The prechop forceps are inserted in the center of the nucleus supported by a manipulator. The
prechop forceps and the core of the nucleus need to be aligned on the same axis. (B) The prechop forceps are opened gently until
complete rupture of the posterior dish of the nucleus, which makes it possible to see the posterior capsule. (C) The 2 nuclear frag-
ments are rotated 90 degrees using the manipulator and closed prechop forceps. (D) Holding the nucleus still with the manipulator,
we insert the prechop forceps into the core of the proximal heminucleus. (continued)
 Phaco Chop Technique  69

F
E

G
H

Figure 4-8. (continued) (E) The prechop forceps are separated again to obtain cracking of the proximal heminucleus. (F) The
prechop forceps are inserted with blades closed into the distal heminucleus and stabilized by the manipulator. (G) The nucleus is
divided by gently separating the blades. (H) Normally the nucleus is split into 4 parts; however, for hard nuclei, with a degree of 4 or
5, smaller pieces should be obtained. The 4 fragments are separated into 8 in order to make their emulsification simpler.
70  Chapter 4
Figure 4-9. Detail of cracking forceps.
into consideration when the capsule is first opened. This
procedure must be fairly central to then progress toward
the edges using a high molecular weight and high viscosity
VES to avoid rhexis escape. The surgeon may find it use-
ful to perform hydrodelamination with the cannula used
for hydrodissection; however, in this case, it is penetrated
deeper into the lens material until the surgeon perceives
greater resistance to the maneuver. At this point, the sur-
geon injects the fluid to separate the nucleus from the layers
above (epinucleus and cortex). Sometimes, a golden ring is
formed that outlines the nucleus. This surgical step involves
separating the various components of the lens to expose it
to the successive maneuvers of phacoaspiration and facili-
tate the rotation of the lens.
When the patient is young, aspiration with the U/S or
the infusion/aspiration (I/A) tips is recommended. In the
juvenile or posttraumatic forms, a monomanual “in situ”
technique with very low values of vacuum and short bursts
of U/S is advisable. The “chip-and-flip” technique or the
2/4 fractions are also valid options. These involve the cre-
ation of a central groove to 2/3 of the nuclear depth, the U/S
tip is occluded in 1 of the nuclear portions that is separated
and aspirated. The techniques based on the central groove
make an important contribution to resolving the problems
associated with the poor consistency of the nucleus: the sul-
cus must be at least twice as wide as the tip because, as the
groove is being carved, the walls will tend to collapse and
obscure the surgeon’s vision of the phaco tip. This will also
limit the possibility of movement. The depth of the groove
must be 80% to 90% of the lens thickness to allow succes-
sive aspiration. The procedure must focus on the aspiration
component (low values in the initial phase, higher values
in the second phase) as opposed to the flow rate (that must
remain high) and the power of the U/S bursts that are
used sparingly using linear control. This technique is easy
to learn, rapid to perform, and associated with few com-
plications even though the management of soft cataracts
requires more careful attention than other forms.
The Grade 2 nucleus is found in juvenile, presenile, and
posttraumatic cataracts. The nuclear material is fairly soft
and the nucleus is slightly harder and more consistent than
the epinucleus. It is essential to control the capsulorrhexis
with a high molecular weight, and high-viscosity VES with
a low shear rate to counter the tendency to escape. A nucleus
of this type can be removed using the four-quadrant tech-
nique, the 2/4 fractional technique, the “stop-and-chop”
technique or the “chip-and-flip” technique. The techniques
of nuclear fracture are preferable, as they tend to require
lower values of U/S and less time is needed to eliminate the
nuclear material.
The Grade 3 nucleus is often seen in clinical practice
and is the form of nucleus that is easiest to remove with
phacoemulsification. There is no specific elective technique
since a hard nucleus can be managed with a number of pro-
cedures; however, the chop techniques are preferable: they
are more rapid and efficacious, associated with reduced val-
ues of U/S, have fewer risks compared to other techniques
because the nuclear fracture maneuvers are performed
principally at the center of the capsular bag, and at a safe
distance from the endothelium and from the posterior cap-
sule. The surgeon avoids sculpting the grooves—a process
that often results in traction on fragile zonules. The use of
U/S is reduced and less intense because the nucleus is sub-
jected to a mechanical fragmentation.
Endocapsular techniques, chip-and-flip or crack-and-
flip—techniques that act directly on the harder central
nucleus, leaving the epinucleus in place as protection and
as a buffer against the maneuvers in the nucleus protecting
the posterior capsule and the zonules—are indicated when
hydrodissection and hydrodelamination highlight a central
nucleus and an epinucleus.
The Chop technique is indicated in the event the
hydrodissection procedure has been efficacious but no
hydrodelineation is observed—in other words, there is no
cleavage between the nucleus and the epinucleus. Surgeons
who are learning this technique should perform it under
peribulbar anesthesia because this patient is almost always
elderly with poor cooperation, so the ocular tissues are
more fragile—the zonules in particular—and this contrasts
starkly with the consistency of the nucleus. The cortex and
the epinucleus are not predominant features and provide a
thin barrier for the posterior capsule. The cornea must be
protected with an adhesive VES that will remain adhered to
the endothelium for the entire operation.
A Grade 4 nucleus corresponds to the typical amber
cataract observed in the elderly and in severe myopia.
Shepherd’s endocapsular phaco with cross-shaped nuclear
fracture is recommended. Alternately, the surgeon may
opt for the phaco chop. This surgery should only be per-
formed by expert surgeons. Young, more inexperienced
surgeons should always consider prolapsing the nucleus
 Phaco Chop Technique  71

into the anterior chamber and performing an extracapsular
extraction.
The Grade 5 is an extremely hard, dark brown nucleus
that should be tackled by expert surgeons who should use
Nagahara’s chop technique with avant-garde instruments
and an appropriate VES. Maximum caution is required, as
these patients are usually very elderly with loose zonules
and iris dystrophy. Consequently, the incidence of compli-
cations may be high. If, after the first phase of phacoemul-
sification, the procedure appears to be increasingly complex
and risky, or if it necessitates excessive manipulation, the
surgeon should convert to an extracapsular extraction.

SUMMARY OF THE PHACO TECHNIQUE BASED ON THE HARDNESS OF THE NUCLEUS

Endocapsular techniques that should Other techniques for use with an open
only be used with an intact rhexis rhexis and/or with a can-opener
Hardness of the Suggested technique Suggested technique
nucleus
Grade 1 ● I/A alone Phaco with the in situ technique
● I/A with the U/S tip
● In situ monomanual technique
Grade 2 ● 2 to 4 fractional ● Technique in anterior chamber
● Chip-and-flip ● Minimal lift
● Cut and suction
● Monomanual phaco
Grade 3 ● In situ monomanual or bimanual ● Minimal lift technique in posterior chamber
technique ● Carousel technique in anterior chamber
● Chip-and-flip
● Crack-and-flip
● In situ fracture
● Trench divide and conquer
● Stop-and-chop
Grade 4 ● Crack-and-flip ● Technique on the pupillary plane
● Phaco chop ● Minimal lift technique
● Crater divide and conquer ● Sectorial technique in the anterior chamber
● Four-quadrant technique ● Extracapsular
Grade 5 ● Phaco chop ● Conversion
● Phaco crater ● Extracapsular

Akaoshi T. Phaco Prechop: Mechanical Nucleofracture Prior to

REFERENCES
1. Can I, Takmaz T, Cakici F, Ozgül M. Comparison of Nagahara
phaco-chop and stop-and-chop phacoemulsification nucleotomy
techniques. J Cataract Refract Surg. 2004;30(3):663-668.
BIBLIOGRAPHY
Phacoemulsification, The Frontier of Ophthalmology in the 21st
Century. Tianjin Science and Technology Press; 2001:288-322.
Fine IH. Choo-Choo Chop and Flip With the Soft Shell Technique Is
Safer and More Efficient. Phaco & Foldables; 1997.
Kamoi K, Mochizuki M. Phaco forward-chop technique for managing
posterior nuclear plate of hard cataract. J Cataract Refract Surg.
2010;36:9-12.
Kim DB. Cross chop: Modified rotationless horizontal chop technique
for weak zonules. J Cataract Refract Surg. 2009;35:1335-1337.

Akaoshi T. Phaco Prechop: Manual Nucleofracture Prior to

Phacoemulsification, Operative Techniques in Cataract and
Refractive Surgery. W.B. Saunders. Vol. 1. 1998:69-91.

Microincision Cataract Surgery
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
From Daviel’s time to now, the aim of cataract surgery
has been to minimize ocular trauma1 and ensure good
postoperative vision, preventing the induction of astigma-
tism2 and correcting preexisting conditions. Sir Harold
Ridley made a significant contribution in 1949 when he
implanted the first intraocular lens (IOL) of PMMA, as
did Kelman in 1967 when he started a revolution with the
idea of phacoemulsification. Since then, cataract surgery
has made huge progress, aimed at reaching 1 objective:
decreasing surgical trauma by refining the technology used
for removing cataracts, improving the stability of the eye
during surgery, and decreasing the size of the incision for
implanting IOLs with a subsequent rapid recovery of vision.
The goal of obtaining ever smaller incisions has recently
divided surgeons into 2 distinct groups: 1 group supports
the sleeveless phaco technique through 2 separate incisions,
while the other group favors coaxial microphaco through
2.2- or 1.8-mm incisions.
Both techniques allow surgery to be performed under
topical anesthesia, which, in turn, speeds up procedures
and reduces a patient’s physical/psychological stress.
In reality, opinions are not equally divided: some sur-
geons believe that the 2-handed technique has many advan-
tages over the coaxial method, and that the latter belongs to
the past. Others believe that the 2-handed technique has no
place, as there are no IOLs suited to a 1.2-mm incision, and
as performing coaxial microphaco through a microtunnel
is now possible, the real difference in the incision is mini-
mal. Both techniques are valid and, if possible, should be
part of the cultural heritage and practical armamentarium
of all surgeons (Figures 5-1 to 5-4 and 5-6).
- 73 -
5
ADVANTAGES AND DISADVANTAGES
Microincision cataract surgery (MICS) is the latest tech-
nique and is also known as 2-handed phaco, cold phaco,
microphaco, and phaconit. It has been made possible by
technological progress of machines and by the commitment
of surgeons.
In 2001, J. Aliò defined it as a phaco technique per-
formed through an incision of less than 2.1 mm. It was first
proposed by Steve Shearing in 1985 and many other sur-
geons later claimed it as their own invention: among these
are H. Fine, R. Packard, and J. Aliò. The first “2-handed”
or “noncoaxial” procedure was performed without a sleeve
through a 1.7- to 1.5-mm incision.
Although the technique is very similar to standard
phaco, it is different in that it calls for the use of different
instruments (trapezoidal blades that create an incision that
is wider on the outside than on the inside, dedicated capsu-
lorrhexis forceps, irrigating choppers, phacoemulsification
machines designed to optimize their performance, such
as the Infinity, Stellaris, and Signature that have advanced
fluid properties for preventing postocclusion surge, and
an U/S management system to prevent corneal burns dur-
ing sleeveless phaco). While the technique is similar, the
approach is different.
As the infusion line is separated from the aspiration/
phaco line, the surgeon must use both hands to perform
the procedure: 1 hand is used for the irrigation instrument
(chopper and/or manipulator) and the other holds the phaco
handpiece (U/S and aspiration), and both instruments must
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 73-78).
© 2014 SLACK Incorporated.
74  Chapter 5
Figure 5-1. After removal of the anterior cortex, the phaco tip is
occluded and the first fracture is performed with the irrigating
chopper.
Figure 5-3. The 2 instruments, irrigating chopper and U/S tip,
work in synchronization to divide and fragment the nuclear
material.
work in continuous, constant harmony during the phaco.
This limits the choice of surgical fragmentation techniques.
The 2-handed technique, when compared with classical
coaxial phaco, according to its supporters, offers various
advantages: a less-invasive approach, no induced astig-
matism (less focal flattening of the corneal periphery and
less irregularity of the corneal surface), low U/S emissions,
Figure 5-2. The nucleus is then rotated and the second fracture
is performed by putting the U/S tip in occlusion.
Figure 5-4. The second heminucleus is divided and fragmented.
better followability of nuclear fragments due to decreased
repulsion at the tip (as the irrigation flow does not oppose
the aspiration flow), stability of the anterior chamber,
and faster visual rehabilitation. In effect, with the coaxial
method, grasping nuclear material can be more difficult, as
the irrigation flow from the sleeve tends to move fragments
away from the phaco tip, even if with the Ozil coaxial tech-
nique, but you can achieve excellent followability. Despite
these positive aspects, it is not used frequently as it calls for
a significant change in mentality and dexterity compared

to traditional surgery. According to its detractors, this is
also because it increases the risk of damaging the tissue
that is emulsified, uses less regular infusion than seen with
coaxial techniques, increases the duration of the procedure,
creates difficulties in finding lenses for a 1.5-mm incision,
and these lenses also tend to be expensive and are difficult
to inject/insert. Supporters of the one-handed technique
stress the shorter phaco time (effective phaco time) even
if, in reality, the difference between the amounts of energy
delivered by the 2 techniques is actually minimal.
In addition to this, the removal of nuclear and corti-
cal fragments is facilitated by the fact that the surgeon, by
changing the 2 instruments, has 360-degree access to the
anterior segment; the irrigation cannula can be used to
retract the iris to allow for better visibility of the posterior
area or to mobilize fragments of the nucleus in the corner
of the chamber or near the incision.
The other method for performing MICS is the micro-
coaxial technique; there is no learning curve and the
2.2-mm incision is, in effect, astigmatic neutral.3 Regarding
chamber stability, both groups maintain better control over
fluid characteristics: the 2-handed technique supporters
claim that the chamber remains more stable as the fluid
enters through 1 part of the eye and exits from another,
resulting in no competition between irrigation and aspira-
tion in the area where fragmentation takes place. It is, how-
ever, also true that the surgeon frequently has to resort to
an anterior chamber maintainer, as the irrigating chopper
does not provide sufficient irrigation to maintain constant
chamber stability and can create a continuous leak from
the incisions (due to the absence of the sleeve) that is not
even compensated by raising the bottle above the normal
levels of a standard phaco. It appears that the presence of
the sleeve allows better fluid balance between entry and
exit to be maintained and, as a result, even when working
with high values of vacuum or flow, there are minimal or
imperceptible fluctuations in the chamber (according to
coaxial supporters).
Another aspect to consider is the thermal effect in
cataract surgery using a microincision. In standard phaco-
emulsification, the phaco U/S tip is cooled by fluid passing
between the silicone sleeve that surrounds the U/S tip.
In effect, if for any reason this gets blocked (by a nuclear
fragment, viscoelastic, or a combination of both), the inci-
sion may be burned. Currently, this does not happen often,
as now nearly all machines in use have efficient systems
that greatly reduce any risk of tip overheating. If blockage
occurs in MICS, the surgeon has failed to observe some
safety margin and this can represent a significant level of
danger. It goes without saying that this does not occur fre-
quently, but it can happen when U/S is used over protracted
periods (hard nuclei), when a high-viscosity viscoelastic
substance is used or when the surgeon has a “heavy hand”
due to unforeseen difficulties in the procedure, and this
can therefore increase friction between the tip and the
Microincision Cataract Surgery  75
wound. New software for improving phaco machines has
been developed to enhance fluid dynamics, but especially
to reduce the risk of thermal damage. This software is ideal
for both 1- and 2-handed techniques.
In reality, each surgeon needs to assess his or her own
technique and consider which is the safest to achieve the
desired aim of the procedure—the safe removal of a cata-
ract and the recovery of vision while not reducing the size
of an incision at any cost.
The size of an incision is especially related to postop-
erative astigmatism: the smaller the incision, the lower the
amount of induced astigmatism. With this in mind, the
2-handed surgeons should provide better results than their
coaxial counterparts; however, the latter are preferable
because the learning curve is less steep, the instrumentation
needed is already in use, and the type of incision involved is
more easily closed and heals more quickly. Constant devel-
opments in coaxial surgery will eliminate the disadvantages
of incisions measuring from 1.8 to 2.2 mm compared with
the 1.5-mm incision of the 2-handed technique.
There appears to be a statistically valid difference
that shows less use of balanced salt solution (BSS) in the
2-handed technique. According to MICS supporters, this
is probably due to the instruments used in the technique
that adapt better to the incision and let less fluid exit, and
because the surgeon can work with no leakage from the
tunnel. This brings about better stability in the anterior
chamber and also results in less damage to the endothelium
(which, in reality, also depends on other conditions), less
postoperative inflammation, a lower rise in pressure, and,
in general, less operative trauma. The decrease in the use of
BSS is, in effect, irrelevant, as it has not been shown that any
greater increase in BSS use causes more endothelial damage
or postoperative inflammation.
Another interesting aspect is an analysis of incisions in
MICS and coaxial procedures. A study by Boukhny demon-
strated that sleeveless phaco produces 5.5 times more stress
at the incision than a sleeve phaco. Even if, in a coaxial pro-
cedure, emulsification of the nucleus takes place through
a 2.2-mm incision instead of a 1.2-mm one, the incision
does not get distorted, meaning that, unlike using the
2-handed method, there is no need to enlarge the incision
to introduce the lens. Especially considering the buffering
effect of the silicone sleeve, the slightly larger incision pro-
vides improved comfort in intraocular maneuvers and the
phaco tip works more smoothly like an oar in a rowlock.
All things considered, a nondistorting incision provides
excellent self-sealing properties unlike in MICS procedures
where distorted incisions often remain open and require
sutures with inherent risk of endophthalmitis. In effect,
when a round metal tube is inserted through a linear inci-
sion, especially if this is narrow, it changes the shape of the
incision, thus increasing the stress on both sides hindering
self-sealing.
76  Chapter 5
Presently, the real limit of MICS is the lack of IOLs for
microincisions. Some companies are already manufactur-
ing microincision lenses between 1.8 and 1.5 mm, (eg, the
MicroSlim and the SlimFlex [Physiol] IOLs that can be
implanted through a 1.5-mm incision). The AcryTec family
(Zeiss) can be injected through a 1.7-mm incision using an
AcrySmart or AcryShooter injector, or we have the Akreos
MI60 (Bausch & Lomb) that can be implanted through a
1.8-mm incision, or the AcrySof that is prefitted with the
AcrySert system that uses a 2.2-mm incision. In general,
however, we can say that there are no IOLs with the optical
qualities of most of the IOLs that are presently available. A
Miyake Apple study demonstrated the presence of vacuoles
inside thin lenses and an unexceptional qualitative refrac-
tive index with subsequent undesired optical effects and a
higher incidence of opacity of the posterior capsule due to
the fact that the edge of the microincision IOL was too thin
to prevent or block the migration of cells from the lenticular
epithelium. This, therefore, explains the increased frequen-
cy of YAG capsulotomies on eyes with microincision lenses.
Currently, the balance is tipping in favor of coaxial
micro-phacoemulsification that allows the use of all the
B-MICS Surgical Technique
1. Topical anesthesia
2. Creation of two 1.2 mm paracentesis with clear cor-
neal incision, 90-degrees apart, at 10 and 2 o’clock
3. Injection of viscoelastic substance into the anterior
chamber
4. Execution of 5-mm capsulorrhexis with specially-
designed forceps or cystotome
5. Hydrodissection
6. Introduction of an irrigating chopper in 1 paracen-
tesis and of the phaco tip in the other, which must
be enlarged to 1.8 mm
7. Creation of a small horizontal groove that is neces-
sary for nucleus fracture later on
8. Parameters used: 100% US and 60 mm Hg vacuum
9. 90-degree rotation of the nucleus
10. Creation of more cracking with the phaco tip and
irrigating chopper
11. Pulsed mobilization and removal of the fragments
12. Parameters used: 60% US and 400 mm Hg vacuum
13. Aspiration of residual masses
14. IOL implantation
soft lenses currently available. Using currently available
injectors and a little variation in the IOL injection method
(contrarotation with a second instrument), it is now pos-
sible to implant a flexible 6.0-mm IOL through a 2.2- to
2.4-mm incision.
THE BENEFITS OF
TWO-HANDED PHACO VERSUS
COAXIAL TECHNIQUES
● The incisions are smaller and safer: 1.2 mm inside and
1.4 mm outside. They are trapezoid shaped and are
separated from each other by 60% to 90%. They are
relatively long and not perpendicular to the corneal
surface to allow the instruments to move smoothly and
to keep the anterior chamber stable.
● The fluid dynamics are better and contribute to ante-
rior chamber stability.
● The followability is better, as irrigation fluid enters
through 1 incision and exits through another.
● The irrigation chopper can be used as a manipulator
(even if it is larger and can create distortions and prob-
lems of internal manipulation).
● There is more flexibility when positioning for irriga-
tion, aspiration, and manipulating the phaco tip.
● MICS is often indicated for “difficult” cases, such as
small pupils, zonular dehiscence, PEX, posttraumatic
cataracts, floppy irises, postvitreous surgery cataracts,
or glaucoma.4,5
● The learning curve, however, needs to be taken into
account. MICS is initially “awkward” for a number of
reasons:
○ The maneuver needed to perform the capsulor-
rhexis is made with the fingers, not the wrist.
○ There is little room for maneuvering instruments.
○ The irrigating chopper is big enough to be used for
rotating and flipping the nucleus.
○ IOL injection takes place in a “soft” eye and through
a smaller incision.
 Microincision Cataract Surgery  77

Figure 5-6. Bimanual MICS. (A) After the capsulorrhexis

and hydrodissection, the 2-handed phaco starts. (B) With
the chopper, each heminucleus is further divided, using
the U/S tip as well. (Reproduced with permission from G.
Cavallini.) (continued)

Figure 5-5. Visalis V500 (Zeiss).

78  Chapter 5

C D

Figure 5-6. (continued) (C) Once a trench is created, the nucleus is divided into 2 parts, using the U/S tip and irrigat-
ing chopper. (D) The nucleus fragments are emulsified.

3. Kaufmann C, Krishman A, Landers J, Esterman A, Thiel MA,

REFERENCES
1. Gomoa A, Liu C. Bowl-and-snail technique for soft cataract.
J Cataract Refract Surg. 2011; 37:8-10.
2. Hayashi K, Yoshida M, Hayashi H. Postoperative corneal shape
changes: microincision versus small-incision coaxial cataract
surgery. J Cataract Refract Surg. 2009;35:233-239.
Goggin M. Astigmatic neutralit in biaxial microincision cataract
surgery. J Cataract Refract Surg. 2009;35:1555-1562.
4. Kurz S, Krummenauer F, Thieme H, Dick HB. Biaxial microinci-
sion versus coaxial small-incision cataract surgery in complicated
cases. J Cataract Refract Surg. 2010;36:66-72.
5. Kim EC, Byun YS, Kim MS. Microincision versus small-incision
coaxial cataract surgery using different power modes for hard
nuclear cataract. J Cataract Refract Surg. 2011;37:1799-1805.

Irrigation and Aspiration
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
GENERAL PRINCIPLES
The next step in phacoemulsification is removal of
the cortex. This is an important time during the surgery
because, like all the other parts of the operation, it needs
to be performed correctly, because it may give rise to com-
plications (eg, dislocation of the capsule and removal of
the bag) that can jeopardize a good outcome. In addition,
if not performed accurately and completely, it may lead to
posterior capsule opacification and post-op inflammation.1
Understanding irrigation and aspiration principles and
techniques allows the surgeon to approach cortical removal
in an organized and safe manner.
Knowledge of the lens anatomy and exact performance of
the previous steps is useful in this case. A regularly shaped
and size capsulorrhexis and accurate hydrodissection make
this surgical phase simpler, faster, and more complete. In
terms of the capsulotomy, the former eliminated the pres-
ence of anterior capsule flaps, which may be engaged by
the aspiration opening; capsular continuity offers greater
strength of the capsule, allowing the surgeon greater free-
dom of action. In addition, the edge of the capsulorrhexis
prevents, or at least limits, the possibility of aspirating the
iris, even a small capsulorrhexis may hinder access of the
aspiration cannula to the lens equator. Hydrodissection2
determines the quantity and adhesion of the cortex; if per-
formed accurately, it makes it possible to aspirate most of
the cortical material along with the epinucleus leaving only
remnants attached to the capsule, which can be removed
with vacuum maneuvers (Figure 6-1).
During hydrodissection, it is possible to separate the lens
cortex into 2 layers3: supranuclear and peripheral. The for-
mer surrounds the nucleus and is the soft enclosure, which
- 79 -
6
possesses a high degree of followability. The peripheral
cortex, as its name suggests, is located between the anterior
capsule (in the equatorial region) and the posterior capsule;
it tends to have more fibrous material, and the intralen-
ticular cells maintain a pseudometaplastic fibrosis capac-
ity. These cells are involved in the thickening of the lens
anterior capsule, which leads to a solid attachment of the
cortex to the capsule in this area—an attachment that is not
present in the adjacent posterior capsule. This characteris-
tic is important to consider during cortical fiber aspiration,
as the peripheral cortex requires a stripping action from
the equator and anterior lens capsule to obtain meticulous
cortical cleaning.
To sum up, the cortex may be free and mobile in the
anterior bag or adhere to the posterior capsule. In this
first case, it has a downy appearance, is soft, and is mostly
located in the anterior chamber in front of the iris. The
adhering cortex is often layered, like an onion, and can
be easily aspirated at times, but more difficult to remove
other times. However, the entire Irrigation/Aspiration (I/A)
procedure takes place inside the capsular bag and must
meet a series of requisites:
1. Safety: maneuvers must not damage intraocular struc-
tures, in particular the posterior capsule, zonules, and
iris.
2. Progression: small flaps of cortex need to be gradually
aspirated to reduce the traction force to a minimum,
which is applied on the capsule and zonules to prevent
removal of the bag.
3. Gradualness: the cortex must first be removed from the
capsule and then aspirated to the center of the ante-
rior chamber; twin cannulas may be useful because
the irrigating cannula helps during the detachment
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 79-85).
© 2014 SLACK Incorporated.
80  Chapter 6
Figure 6-1. Two-handed aspiration. One cannula irrigates and
the other aspirates the cortex and material adhering to the pos-
terior capsule with a gentle vacuum cleaner movement.
Figure 6-3. Sanded aspiration tip for 2-handed technique.
Figure 6-5. Silicone sleeve.
maneuver and aspiration cannula during the removal.
The vacuum should be set linearly so that it is brought
to maximum levels only when the cortex is completely
detached from the capsule.
4. Speed: the maneuver to remove the cortex should be
fast, but respect the progression and gradualness to
avoid constriction of the pupil and endothelial injury
in the event of long aspiration and slow and repetitive
movements.
5. Effectiveness: adequate settings need to be used that
vary from 1 phaco machine to other and the type of
handpiece.
6. Completeness: all cortex remnants need to be com-
pletely and accurately removed to prevent post-op phi-
mosis, reduce the risk of posterior capsule opacity, and
improve vision quality (Figures 6-2 to 6-7).
Figure 6-2. Typical handle for irrigation and/or aspiration can-
nulas for 2-handed technique.
Figure 6-4. Tip with 2 irrigation holes for 2-handed technique.
Figure 6-6. Coaxial tip with metal sleeve.
IRRIGATION/ASPIRATION TIPS
Various handpieces are available with irrigation–
aspiration tips that have aspiration openings with different
diameters (ie, 0.2 to 0.3 to 0.5 to 0.7 mm).
The tips with 0.2- to 0.3-mm opening are used to remove
very small cortical fragments because of greater occlusion
ease and are designed to be used with maximum vacuum
levels because they are more selective. The 0.5 to 0.7-mm
tips must be used with low vacuum for larger cortical
portions; using higher values here poses a risk of anterior
chamber collapse and aspiration of the iris or posterior
capsule.
The most commonly used aspiration tip is with a
0.3-mm opening, as it allows efficient aspiration and mini-
mizes the possibility of accidental capture of the posterior
capsule. It makes it easier to remove all types of cortex,
layered, adherent, floating, both small and large fragments,
and thus makes the procedure faster and provides a good
balance between irrigation and aspiration, which means a
constant depth in the anterior chamber.
Coaxial I/A tips can be straight or angled 45 or
90 degrees. A straight tip allows easy access to the cortex for
180 degrees from the main incision, but makes it difficult
to remove the subincisional cortex; a 90-degree tip helps
aspirate the subincisional cortex but hinders removal of the
 Irrigation and Aspiration  81

A B

C D

E F

Figure 6-7. Various irrigation and aspiration cannula ends: (A) straight, (B) 45 degrees, (C) 90 degrees, (D) hook, (E)
coaxial thin metal, (F) angled.

cortex material opposite the incision. The 45-degree inter-
mediate tip is useful for almost all maneuvers. Removal of
the subincisional cortex may be made easier by mobilizing
the cortex in various ways:
1. The I/A tip is oriented so that the aspiration hole is
positioned laterally and, once the fragment is captured,
it is again rotated toward the surgeon and aimed in the
opposite direction at the same time in order to progres-
sively detach the nuclear material.
2. With a spatula, the cortex is mobilized under the I/A
tip, while the anterior chamber is kept very deep only
with irrigation.
3. The I/A tip is removed and a Sauter cannula (the same
one used for hydrodissection) is inserted through the
paracentesis connected to a syringe filled with BSS to
mobilize the remaining cortex under the incision.
4. With the I/A tip, the iris is massaged under the inci-
sions, and keeping the pedal in position 1 with lateral
movements, the cortex is mobilized until a fragment is
accessible to the aspiration port.
5. It is possible to reduce the level of vacuum and directly
aspirate the material adhering to the posterior capsule
with the aspiration hole facing the material (vacuum
maneuver).
6. It is possible to use a curved tip to perform a right–left
and backward–forward movement with the pedal in
position 2 until the cortex is grasped; at this point, the
pedal is pressed in position 3 to reach the maximum
vacuum level.
7. The bimanual technique is discussed in the following
section.
COAXIAL OR BIMANUAL
Cortical aspiration can be performed using a coaxial or
bimanual technique. The first is the most popular and has
been used since phacoemulsification originated: both irri-
gation and aspiration coexist in the I/A handpiece, which
has an external irrigating sleeve that surrounds a central
aspiration port. However, due to the diameter (smaller than
a U/S handpiece), the tunnel remains partly open and, con-
sequently, there is anterior chamber instability. No sleeve,
either metallic or silicone, ensures a perfect seal of the
82  Chapter 6
A B
Figure 6-8. (A,B) Coaxial handle. Aspiration and infusion exist in the same handle.
main incision and thus a good maintenance of the anterior
chamber. The silicone sleeve, like the U/S handpiece, must
be positioned so that the aspiration port faces the surgeon
and remains like this during all the phases; the irrigation
ports are positioned laterally.
The dimension of the coaxial handle requires a high
flow to keep the anterior chamber deep and prevent a sec-
ond paracentesis. The end of the handpiece needs a sleeve,
which can be silicone or metal. The former is preferable for
various reasons:
● It is soft and adapts well to the shape of the incision;
this allows the anterior chamber to maintain a stable
depth no matter what the tip position, since only a
small amount of fluid comes out of the incision, unlike
that occurring with a metal tip—since it is rigid, it
opens the upper and lower edges of the tunnel with a
lot of leakage, particularly when moving laterally or
vertically.
● It does not reflect light from the microscope, which
may bother the surgeon.
● Since it is transparent, it allows good visibility of the
anterior chamber (Figure 6-8).
On the other hand, a bimanual approach4 involves infu-
sion and aspiration with 2 separate handpieces. These small
handpieces are inserted in the anterior chamber through
2 lateral opposite paracenteses at around 50 degrees from
the tunnel and are performed with 15- and 30-degree
knives or with a precalibrated 1.5-mm blade; the incision
can be tangential to the iris plane and have a trapezoid
shape.
The external opening (1.6 to 1.8 mm) must be wider
than the internal one (1 to 1.2 mm) to facilitate entry of
the cannula. The internal incision must be slightly larger
than the cannula diameter to reduce BSS leakage, which
makes the anterior chamber unstable, and to avoid forma-
tion of corneal folds, which reduce visibility. An opening
with these characteristics helps spontaneous closure. The
2 handpieces are used interchangeably, allowing access to
the subincisional space and better capsule management in
all its recesses, especially for small pupils, small capsulor-
rhexis, floppy iris, or posterior capsule rupture. In addition,
it is possible to remove the cortex in a less traumatic manner
by detaching it with infusion and making aspiration easier.
The small incisions ensure better flow and outflow control,
improving anterior chamber stability. The 2 cannulas are
slightly curved: the irrigation cannula has 2 0.5-mm holes
before the end, located at the 2 opposite sides of the cannula
along the axis perpendicular to the curve of the cannula;
the aspiration cannula has a single 0.3-mm opening located
on the concave side around 1 mm from the end. The han-
dles are available in steel, aluminum, or titanium. Titanium
is the best and lightest material (Figures 6-9 to 6-11).
The 2 ends can be closed and the holes positioned along
the handpiece; this limits the risk of detaching Descemet’s
membrane when inserting the cannula in the anterior
chamber and reduces the danger of posterior capsule rup-
ture if the anterior chamber is shallow. The end of the aspi-
ration cannula can be sanded, which allows the surgeon to
use it for cleaning the posterior capsule or the inner surface
of the anterior capsule. The best aspiration hole diameter is
0.3 mm, it is 0.5 mm for irrigation holes.
The advantages can be summarized as follows5:
● The 2 cannulas can have exactly the same diameter
(the best is 23 gauge) in order to be inserted alternative-
ly from the 2 incisions to easily reach all 360 degrees of
the capsular bag.
● This is basically a closed-system technique: the tunnel
incision is closed by internal pressure; the 2 second-
ary incisions are too small to let a significant quan-
tity of fluid leak out and are mainly obstructed by the
cannulas.
● This is a positive-pressure technique: the increase in
internal pressure causes a general distension of the
capsular bag, above all the posterior capsule as well as
the cornea and iris (which induces mydriasis).

Figure 6-9. Two-handed aspiration. One cannula irrigates and
the other aspirates the cortex and material adhering to the
anterior capsule.
Figure 6-11. Any residual nuclear material can be fragmented
using the 2 cannulas.
● The cornea is always distended, and this means a reduc-
tion or absence of folds with subsequent improved vis-
ibility (see Figure 6-1).
● Since the bag and posterior capsule are distended,
they do not have folds so there is less risk of accidental
aspiration; this improves access to the cortical material
and visibility and opens the spaces for working with
the cannula.
● It makes it possible to rub the 2 cannulas against each
other, making it easier to aspirate hard material or
those that are difficult to aspirate.
● It allows retraction of the iris: the irrigation cannula
can be used to retract the iris in the event of miosis and
facilitates the work of the other one.
● It is a fast, easy, and safe technique because it decreases
the risks of capsulorrhexis and posterior capsule
rupture.
Irrigation and Aspiration  83
Figure 6-10. Two-handed aspiration. One cannula irrigates
and the other aspirates the cortex and material adhering to the
posterior capsule.
● It can control globe motility: primarily under topical
anesthesia, it makes it possible to manage and control
eye movements.
● It provides bimanual surgical training in a relatively
simple phase of the operation.
We need to thank Dr. Lucio Buratto for this technique,
which he introduced to modern cataract surgery.
The only disadvantage is the need to perform a second
paracentesis with greater corneal trauma and the tempo-
rary chamber depth instability, because during the occlu-
sion phases, there is practically no leakage and the chamber
tends to deepen.
An alternative consists of inserting the coaxial hand-
piece through the tunnel for infusion and the aspiration
handle from the paracentesis used during the phaco to
insert the second instrument (Figure 6-12).
SETTINGS
The selection of parameters to use is important even if
surgeons establish them based on their experience and the
phaco machine they use. A high vacuum definitely makes
cortex removal faster, while posterior capsule cleaning
requires low vacuum and aspiration for safety reasons.
Before entering the anterior chamber, the surgeon places
the pedal in position 1 to remove air from the infusion
cannula.
The approach to the cortical material must always begin
with the pedal in position 1 so as to create space to opti-
mize the grasp of the cortex by the I/A tip. When this tip
is in contact with the cortical material, the pedal is pushed
slightly more to go to position 2 in order to occlude the aspi-
ration port and increase the vacuum to the maximum value
preset on the device. Once the cortical material is grasped
(occlusion), the tip is pulled slowly toward the center of the
84  Chapter 6

A B

C D

Figure 6-12. (A–D) Two-handed aspiration. A small fragment of epinucleus or nucleus is captured by the aspiration cannula and
mechanically fragmented with the irrigation cannula. Details of the sequence.

pupil in order to progressively detach a triangular wedge of
cortex from the edge toward the center. Alternatively, once
in contact with the cortex material, it is possible to perform
a gentle right–left lateralization or pull and push movement
to make it easier to detach and remove a larger piece of cor-
tex from the posterior capsule. Once the cortex fragment is
freed from the posterior capsule, the I/A tip, with the port
facing the surgeon, is held in the center of the pupil until
the progressive increase in vacuum, caused by pressing on
the pedal, makes it possible to aspirate the entire engaged
cortical fragment. It is best to start from the cortex portions
located in the distal sectors from the incision, even if some
surgeons prefer first removing the subincisional cortex.
The use of ideal parameters or machines with anticol-
lapse systems lets the surgeon perform the entire operation
with maximum safety with excellent control of the ante-
rior chamber depth. Normally, the flow rate is set at 18 to
25 cm3/min and the maximum vacuum at 400 mm Hg with
linear aspiration. Appropriate use of the pedal, flow rate,
and bottle height (normally 80 to 120) helps reduce anterior
chamber fluctuation to a minimum.

CLEANING THE POSTERIOR CAPSULE
Posterior capsule cleaning can be performed by selecting
the specific mode on the phaco machine, which is preset,
or by managing and controlling infusion and aspiration
linearly with the pedal. This maneuver is definitely made
easier by bimanual I/A. In this case, the sanded tip of the
infusion cannula gently and safely detaches cortical rem-
nants with circular movements, minimizing the risk of
posterior capsule rupture. The optimal parameters are 5 to
15 mm Hg of vacuum and 5 to 10 cm3/min of flow rate.
If a cortical plate remains attached to the posterior
capsule after aspirating the sections, there are different
approaches for removing it. To reduce the possibility of pos-
terior capsule rupture, the I/A tip of the single handle can be
placed with the opening vertically or accurately downward
at the posterior cortical material with the setting adjusted
to low vacuum and aspiration values. Then, with a gentle
“scraping” movement, the surgeon tries to lift an edge of the
fibrosis, attempts to mobilize it with a hydrodissection or
viscodissection, and then removes it with extreme caution
because the risk of capsular rupture is high.
If the surgeon has little experience, the cortical layer
adhering to the posterior capsule can be mobilized with a
sanded irrigation cannula attached to an irrigation hand-
piece; alternatively, viscoelastic can be injected and, when
the chamber is very stable, a gentle capsular scraping can be
performed with a tip of the cannula used for the injection or
with a scraper (see Figure 6-10).
Using a bimanual technique, the surgeon places the
infusion cannula in contact with the cortical remnant
adhering to the posterior capsule and gently detaches with
a circular massage movement and then removes with the
aspiration cannula.
If you do not feel comfortable with this maneuver,
it is better to stop and perform a postoperative YAG
capsulotomy.
Otherwise, the intraocular lens (IOL) is implanted and
its rotation inside the bag helps mobilize and detach the
most adherent and stubborn pieces. Another important
time during the I/A phase is removal of the lens epithe-
lial cells as a preventive action against secondary capsular
opacification.
REMOVAL OF VISCOELASTIC
The I/A is used again for viscoelastic removal, both from
the anterior chamber and the capsular bag, after IOL implan-
tation, with high vacuum, aspiration, and infusion values to
Irrigation and Aspiration  85
prevent postoperative increased Intraocular Pressure (IOP)
problems. The viscoelastic, which may remain trapped
behind the IOL, may be removed by an oscillating move-
ment of the lens with the I/A tip; otherwise, by using the
twin cannulas, infusion placed between the lens and poste-
rior capsule and aspiration above the IOL may help remove
it.
The techniques and parameters vary based on the type of
viscoelastic: with a cohesive viscoelastic, the vacuum needs
to be around 400 mm Hg and the flow rate 18 cm3/min
and removal must be performed gradually and quickly.
With dispersive viscoelastic, the parameters are differ-
ent: the vacuum will be around 500 mm Hg and the flow
rate 30 cm3/min. Since this viscoelastic adheres to tissue,
the surgeon should use a fragment aspiration technique:
the aspiration cannula must “look for” the viscoelastic
in the various sections because the substance is not spon-
taneously drawn by aspiration like cohesive viscoelastic is.
The first portion to be removed is the one in the center of
the anterior chamber, second is that within the bag and
around the lens, and last is that located in the corner of the
chamber and adhering to the cornea. In this case, the aspi-
ration cannula is a big help: moving in the anterior chamber
and directing the BSS flow in various directions, improves
mobilization and fragmentation of the viscoelastic and
makes it easier to grasp it and aspirate it.
The effectiveness of irrigation and aspiration requires
understanding the lens anatomy, and the most evolved
instruments and techniques make it easier. A good cataract
surgeon adapts the surgical technique and modifies the
machine parameters, adapting them to each case.
REFERENCES
1. Peng Q, Apple DJ, Visessook N, et al. Surgical prevention of
posterior capsule opacification. Part 2: Enhancement of cortical
clean up by focusing on hydrodissection. J Cataract Refract Surg.
2000;26:188-197.
2. Fine IH. Cortical clearing hydrodissezion. J Cataract Refract Surg.
1992;18:508-512.
3. Henderson BA. Essential of Cataract Surgery. Thorofare, NJ:
SLACK Incorporated; 2007.
4. Reiss G, Dulaney D, Ness J. Bimanual cortex removal. J Ophthalmic
Surg. 1994;25:659-660.
5. Buratto L. Chirurgia della cataratta. Facoemulsificazione
Evoluzione e Stato dell’arte. 1996;2:235-243.

Fluidics and Machines
Lucio Buratto, MD; Stephen F. Brint, MD, FACS; and Rosalia Sorce, MD
For complete training for cataract surgery, it is necessary
to understand and know how to manage events occurring
in the eye during the surgery; so, 2 fundamental things
need to be known:
1. Fluidics in the anterior chamber with the phaco
machine
2. Aspects of function of the phaco machine
All surgical steps performed while the phaco tip is in the
anterior chamber must be done in a controlled manner with
a stable environment with basically constant intraocular
pressure. This means that the depth of the anterior cham-
ber can only vary slightly in order to avoid potential injury
to the eye. If the chamber collapses, internal structures can
come into contact with each other and the instruments
within the eye.
To more easily understand the fluidics and physical
phenomena that take place in the anterior chamber during
phacoemulsification, we can compare the surgical environ-
ment to a closed hydraulic system comprising 1) an irriga-
tion line composed of an infusion bottle and tubing, which
carries the fluid to the handpiece; 2) the spaces in the eye;
and 3) an aspiration line composed of aspiration tubing
connected to the handpiece on one side and to the pump,
which creates aspiration, on the other. Leakage of fluid at
the incisions also needs to be considered.
The flow of fluid from the infusion line may vary based
on the pressure difference between the infusion line and
inside the eye. If there is a flow of fluid coming out of the
anterior chamber (because aspiration via the aspiration
line or leaking out of the incisions), it will proportionally
increase the fluid entering according to Poiseuille’s law.
- 87 -
7
If outflow exceeds the flow capacity of the irrigation line,
the pressure inside the anterior chamber will consequently
decrease.
The outflow in this type of system is by gravity. The
higher the infusion pressure, the greater the height of the
bottle as compared to the eye. To obtain a constant pres-
sure and thus a stable environment, the height of the bottle
and the infusion tube diameter should be able to provide
a positive balance between the inflow and outflow. This
condition ensures stability of the anterior chamber, which
does not occur when the balance is greater on the outflow
fluid side.
Basically, cataract surgery requires fluid flow within the
eye to remove the emulsified nucleus, aspirate residual cor-
tical material, aspirate the viscoelastic, and dissipate heat
created by the phaco tip. This flow depends on the infusion
bottle height, aspiration flow rate, and leakage through the
incisions. Modern phaco machines allow direct or indirect
aspiration flow rate.
Management of flow rate, vacuum, and ultrasound lets
the surgeon control the fluidics within the anterior cham-
ber and maintain stability. Infusion, aspiration, occlusion,
and various modes for using U/S (ie, pulsed and burst)
are other factors that can affect the movement of nuclear
material.
Therefore, before approaching cataract surgery, basic
fluidics must be understood.
A glossary of the terminology used in phacoemulsifica-
tion procedures is provided next. The knowledge of these
elements is mandatory for fully understanding the changes
in fluidics, which occur during surgery.
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 87-97).
© 2014 SLACK Incorporated.
88  Chapter 7
Figure 7-1. U/S tip with its sleeve.
Aspiration bypass system (ABS): A characteristic of the
new phaco tips; it consists of a small hole near the end of
the tip used to maintain aspiration flow even when the tip
is completely occluded. Its advantages include a decrease in
vacuum levels, constant cooling of the tip, and surge reduc-
tion (Figure 7-1).1
Bimodal: Phaco function used for linear control of flow
and vacuum separately from the pedal; it is a position where
ultrasound remains at low levels and the aspiration and
vacuum are moderate.
Burst: It is phaco function where U/S power and dura-
tion are preselected with fixed modes. Off time is managed
in linear mode by the pedal. The burst mode is used to issue
ultrasound “shocks” separated by off time, which progres-
sively decreases by pressing the pedal until there is continu-
ous emulsification; this is useful in the initial chop phase.
The advantages of this function are reduced use of ultra-
sound and an increase in followability. It is recommended
when maximum speed and efficiency are desired and when
operating conditions allow it (ie, when the nucleus is of
average density and all the steps before nucleofracture have
been performed normally); otherwise, the pulsed method
is preferable.
Compliance: This is the ratio between the change in
volume and change in pressure; it measures the elasticity/
rigidity of a certain material subjected to variable pressures
(ie, in phacoemulsification). It measures the aspiration
tubing contraction/expansion due to changes in vacuum/
occlusion, which contribute to surge.
Dynamic rise: It is the ability to change (increase or
decrease) the pump speed at a certain change in vacuum.
The system “feels” the increase in vacuum in the infusion
tubing and increases the intraocular pressure. It identifies
this situation as preocclusion and, thus, increases the aspi-
ration speed, making it faster to reach the preset vacuum
limit. The increase in dynamic rise decreases the rise time
and consequently the turbulence and regulates the time to
create occlusion, improving holdability. For example, a pos-
itive dynamic rise is recommended with chop techniques
for removing segments, making it easier to use initial low
flow and resulting in greater anterior chamber stability, safe
engagement of fragments, and also works well for Venturi
pump users.
Flow: It is the quantity of liquid (measured in cubic
centimeters—cm3/minute) that circulates (enters and exits)
inside the eye per unit of time (minute) coming from
the infusion handpiece; the fluid can flow out of the
eye through the aspiration line, the tunnel, or leakage.
Clinically, this translates into determining the speed at
which hydrodynamic phenomena occur in the anterior
chamber in the various surgical steps: basically, flow affects
the speed at which the material is drawn to the U/S or I/A
tip. There are 3 flow types in phacoemulsification:
1. Infusion: The flow that comes from the bottle, through
the handpiece, into the eye. It may be created by a pro-
grammable pump and regulated by machine settings.
It depends on a gravity system where the pressure is
created by the difference between the bottle height
and patient’s eye (and not between bottle height and
the machine), the tubing resistance, and the handpiece
used. It must be fairly high to anticipate outflow. The
infusion tube usually has a larger diameter and is softer
than the outflow (aspiration) tube because the compli-
ance (ie, the ease with which the tubing collapses) is
lower, unlike the aspiration tube, which must be more
rigid to minimize surge.
2. Aspiration: The flow that exits the eye through the
handpiece (ie, the amount of fluid that is removed
through the aspiration system). Its control is affected
by different factors at the same time: the diameter of
the phaco and I/A tip, tubing dimension, compliance,
vacuum in the Venturi pump, and venting and aspira-
tion settings.
3. Incisional: This occurs through the incision (main or
side port); given that the incision is not sealed, flow
around the instruments is inevitable and, for the most
part, is useful to prevent burning of the tunnel. If the
incision is too large, it may cause damage due to exces-
sive flow and difficulty in keeping the anterior cham-
ber stable. If it is too small and/or too long, it may cause
wrinkling of the sleeve severe enough to compromise
infusion, causing instability of the anterior chamber.
The incision width should be standardized for the
phaco tip and I/A.
Flow rate or aspiration flow rate: The maximum quan-
tity of fluid that can be aspirated from the anterior chamber
by the aspiration line in a preset time; its value is important
because it determines the speed at which things occur with-
in the eye and affects intraocular pressure. It depends on
intrinsic factors, such as pump speed, number of rollers (for
a peristaltic pump), rotating cylinder diameters, and fluid
speed in the aspiration tubing, and extrinsic factors such
as tubing diameter, aspirated fluid density, and aspiration
system. For example, high values accelerate all movements
within the chamber, from the aspiration of lens fragments
to everything that accidentally comes into contact with the
phaco tip, iris or posterior capsule, until reaching maxi-
mum vacuum levels. An increase in aspiration flow rate
corresponds to a decrease in intraocular pressure, which
must be offset by raising the bottle to increase the flow.
Normally in the anterior chamber, which is a system con-
sidered almost closed with a sealed incision, the aspiration
 Fluidics and Machines  89

Figure 7-2. Aspiration flow rate (shown in red) is the volume

of fluid aspirated in a unit of time from the anterior chamber
through the aspiration line connected to the handle.
B
flow rate and flow match. Basically, the aspiration flow
represents the maximum amount of fluid that can be aspi-
rated by the pump within a set time and defines its capacity,
while flow rate determines its volume (Figures 7-2 and 7-3).
Followability: It is the ability to draw fragments to the
U/S tip for emulsification or the ability to leave the phaco
tip in the safest position possible so that the desired frag-
ments come closer instead of having to search for them. It
is directly proportional to the amount of flow and inversely
proportional to the hardness of the nucleus. It is a function
of aspiration flow rate: the greater the flow, the easier the
lenticular remnants move; the softer the cataract material,
the easier it is to grasp it. It is created by 3 parameters that
work together: aspiration, U/S power, and vacuum. All of
these cause gentle movement of nuclear fragments from
their initial position toward the tip to then be emulsified
and removed.
Holdability: It is the ability to hold a fragment on the tip Figure 7-3. (A, B) Aspiration flow rate. The aspiration flow rep-
to be able to emulsify it. It depends on subtle pressure equi- resents the maximum amount of fluid that can be aspirated by
librium between the anterior chamber and aspiration line. the pump within a set time; it defines the pump’s capacity, while
The flow, which measures the amount of fluid aspirated the flow rate defines its size. Normally in the anterior chamber,
from the anterior chamber in units of time, is established which is a system considered almost closed with sealed incision,
based on surgeon’s requirements and characteristics of the the aspiration flow rate and flow match. Its value is important
instrument and determined by aspiration pump speed. because it determines the speed at which the events are per-
formed within the eye and affects intraocular pressure.
Vacuum is the measurement of negative pressure cre-
ated in the aspiration line and generally ranges from 0 to
400 mm Hg based on the type of device and needs at the tip is occluded, vacuum increases progressively, creating
time. By using a peristaltic pump when the aspiration tip aspiration of the material causing occlusion. As long as the
is not occluded, the vacuum is not affected by the action tip remains occluded, vacuum will continue to rise, until
of the pump, which determines flow despite being able the value determined by the machine is reached. Thus, the
to create vacuum correlated to tubing compliance. If the material will stay “glued” to the tip with suction.
90  Chapter 7
Occlusion break surge: The atmospheric pressure com-
presses the aspiration line when there is vacuum in the
tube. The fluid partially transforms into gas at around
300 mm Hg of vacuum, after the occlusion break. The
aspiration line expands and the gas bubbles collapse; this
expansion of the aspiration line and collapse of the gas bub-
bles abruptly draw fluid from the anterior chamber, causing
it to become shallower or to collapse if the surge is severe.
Pulsed, or pulsed mode, is a function of the phaco unit
where the U/S power is emitted in energy “packets” distrib-
uted for certain duration. The surgeon selects the amount
of these pulses by changing the emission frequency: the
higher the frequency, the faster the U/S packets will be
released; and, vice versa, the lower the frequency, the
slower the emission. Distribution of energy in “pulses”
limits chattering compared to continuous delivery and can
reduce surge by preventing sudden occlusion break. The
“micropulse” procedure is an evolution of pulsed mode
and has actually replaced it. The rationale is still to reduce
chattering and reduce the distributed energy for lower heat
generation at the incision and cause less tissue damage. It is
the recommended procedure for surgeons in training due
to its high effectiveness and slow, controlled progression.
Expert surgeons may benefit more from this setting if there
is zonular weakness and a very dense nucleus.
Reflux is a function used to infuse fluid from the aspira-
tion line for a limited period; it can be activated by a button
located on the pedal (switch) and can be obtained by inver-
sion of pump rotation or by derivation from the infusion
bottle. It can be used to remove accidentally aspirated tissue
(above all during I/A). It is a function that is activated at
the pedal.
Rise time is the time to reach the maximum vacuum level
and thus to obtain occlusion.
Surge: It is the volume of fluid aspirated when the occlu-
sion suddenly breaks at the phaco tip (occlusion break)
and an undesired aspiration of fluid due to persistence of a
negative pressure gradient between the aspiration line and
anterior chamber with consequent intraocular pressure
sudden decrease and possible anterior chamber collapse. Its
entity depends on 3 factors: 1) system compliance; 2) vac-
uum level before the surge; and 3) the resistance supplied
by the aspiration line. There are various systems used to
control surge.
Vacuum: This is the negative pressure (less than atmo-
spheric) created by the pump. It represents the aspiration
force, which is needed to pull the material so that it is aspi-
rated; its value is expressed in millimeters of mercury (mm
Hg). Different types of pumps can generate it. Its maximum
limit, called vacuum limit, which represents a safety thresh-
old, is preset by the surgeon and can be changed during the
various surgical steps to permit or prevent tip occlusion
and consequently to prevent anterior chamber collapse or
to ensure management of unforeseen events during the
surgery such as accidental capture of tissues other than
cataract material. The speed for reaching vacuum var-
ies based on the pump type: in a system equipped with a
peristaltic pump, when the aspiration hole is occluded, the
speed with which the maximum vacuum value is reached
(rise time) depends on both the pump characteristics and
the flow value; a peristaltic pump produces vacuum over
a relatively slow time only after occlusion. The vacuum
rise time depends on the pump rotation speed. By using a
Venturi pump, the preset vacuum is also created without
occlusion and is reached in a very short time.
The vacuum level during sculpting with the U/S tip
generally ranges between 0 and 80 mm Hg based on the
type of device and needs at the time: during nuclear frag-
ment removal between 300 and 500 mm Hg and during
cortex aspiration (with the I/A handpiece) between 300 and
600 mm Hg.
With a peristaltic pump, the preset maximum vacuum
value during the phaco portion is reached by occluding the
tip, with a speed directly proportional to the flow value;
during I/A with linear operation of the vacuum level pedal,
with occluded tip, it is regulated by the pressure on the
pedal: by pressing the pedal all the way down, the present
maximum value is reached with a speed directly propor-
tional to the flow value. Basically, vacuum determines the
capacity for holding the nuclear fragments on the phaco
tip. With peristaltic pumps, the vacuum rises only after
occlusion. With a Venturi pump, it rises even without an
occluded tip. In this case, flow is directly correlated to the
amount of vacuum.
Vacuum rise time measures the time it takes for the
vacuum to reach the preset maximum value (ie, the speed
at which the vacuum increases). In peristaltic pumps, this
is inversely proportional to the aspiration flow rate (ie, by
increasing the pump speed, the vacuum rise time decreases
more and more). The machine, or rather its compliance,
also plays an important role. This represents a measure-
ment of how much the fluid circuit (aspiration line) changes
in volume with changes in pressure or increase in vacuum.
For example, in a high-compliance system, the vacuum
created by the pump first acts on the circuit volume, which
acts as a damper. Then, when the changes in volume have
reached the limit, the vacuum is transmitted to the hand-
piece tip and then to the anterior chamber; basically, high
compliance is associated with lengthening of vacuum rise
time. This means a lengthening of surgery time, since aspi-
ration of lens fragments is inevitably slower but certainly
safer in terms of engaging the iris or posterior capsule in the
handpiece aspiration hole; in this case, it is easy to stop it
before reaching the maximum vacuum levels. There is also
a descent time (ie, the vacuum recovery time after unblock-
ing of the aspiration hole) that is faster with fewer undesired
residual aspirations.
Venting is an anticollapse system used to cancel vacuum
present along the aspiration lines as soon as the pedal
is released (normally when moving from position 2 to

Figure 7-4. Peristaltic pump is composed of rollers
mounted on a rotating cylinder; the aspiration tube is
inserted between the system of rollers and the rigid wall
where the pump is housed. When the cylinder rotates,
the rollers compress the flexible aspiration tube and
the fluid contained in it against the rigid surface with an
alternating compression and decompression movement,
generating a pressure gradient along the aspiration line,
which determines movement of the fluid column toward
the rotation direction.
position 1). It can be obtained by inserting air or saline
solution in the aspiration tubing. Its automatic activation
is used to immediately release any accidentally aspirated
tissue when the tip is still occluded and prevents a peristal-
tic pump from exceeding the preset vacuum values. It is
important to understand that venting is not reflux.
Once these concepts are clear, it is necessary to learn
about the various components of a phacoemulsification
device.
THE PUMPS
The pumps are divided into 2 groups2,3: flow and
vacuum.
1. Flow pumps include peristaltic and scroll pumps.
They regulate aspiration flow through direct contact
between the fluid inside the tubing and the rotating
part.
A peristaltic pump is composed of rollers mounted on
a rotating cylinder; the aspiration tubing is inserted
between a system of rollers and the rigid wall where
the pump is housed. When the cylinder rotates, the
rollers compress the flexible (normally silicone) aspira-
tion tubing and the fluid contained in it against the
rigid surface with an alternating compression and
decompression movement, generating a pressure gradi-
ent along the aspiration line, which causes movement
of the fluid toward the rotation direction. The pump
rotation speed can be preset: an increase in speed cor-
responds to an increase in aspirated quantity flow in
units of time (aspiration flow rate), which translates
Fluidics and Machines  91
Figure 7-5. Peristaltic pump. The rotation of the cylinder causes
movement of the fluid column along the aspiration line.
into a shorter time to draw the lens material to the
phaco tip and, once occlusion is obtained, makes it
possible to reach the preset maximum vacuum level
(vacuum rise time). The term comes from the abil-
ity of directly regulating aspiration flow speed using
the pedal position or with the panel controls, while
vacuum levels are regulated indirectly by the amount
of tip occlusion, aspiration line diameter, and preset
maximum vacuum limit (Figures 7-4 and 7-5).
Basically, the peristaltic pump makes it possible to
achieve significant vacuum levels only when the phaco
tip is occluded; no vacuum is generated when there is
no occlusion: if the aspiration tip is occluded, the fluid
flow stops and vacuum is generated, whose maximum
values can be determined ahead of time. When the
material occluding the tip is aspirated, the flow goes
back to normal and vacuum is cancelled. At low rota-
tion speeds, the quantity of fluid aspirated per unit of
time depends on pump speed and aspiration line inlet
hole diameter; at high rotation speeds, the diameter,
length, and flexibility of the aspiration tubing also play
a role; these parameters change the resistance along the
aspiration line so that the pressure difference between
the anterior chamber and pump is increased and thus
the quantity of aspirated liquid in the unit of time. The
following elements affect the system hydrodynamics:
flow, vacuum and vacuum rise time, occlusion,
venting, and reflux. Actually, occlusion, more than
being a fundamental element of hydrodynamics, is
an effect of the vacuum and partly the flow. Basically,
when the aspiration port remains open (nonocclusion
condition), there is only an aspirated fluid flow with
almost zero vacuum. By closing the aspiration port
(creating an occlusion), the pump cannot aspirate fluid
from the chamber and thus generates vacuum inside
the aspiration tubing up to the maximum level preset
on the instrument. The vacuum is used to draw the
fragment of cataract, which is occluding it into the
aspiration line. The flow (cm3/min) is controlled by
92  Chapter 7

A B

C D

Figure 7-6. Peristaltic pump. (A) Representation of peristaltic pump operation used to achieve
significant vacuum values when the phaco tip is occluded: like an olive at the bottom of a glass,
if there is aspiration with no occlusion in phaco, the vacuum cannot be increased and solid
bodies are not drawn to the tip; only fluids are aspirated. (B) If the straw (phaco tip) is obstruct-
ed, the fluids cannot be aspirated; by continuing to breathe in, the vacuum increases and the
olive is drawn closer. The vacuum rises the same way in a phaco aspiration line. (C) The negative
pressure is maintained if both ends of the straw are obstructed (1 by the olive, the other by the
tongue). In phaco, this all corresponds to reaching the maximum vacuum. (D) When the occlu-
sion disappears, so does the vacuum.

the pump speed (rpm) and determines the vacuum rise
time. The higher the pump speed (with flow equal to
zero), the shorter the time needed to reach the preset
vacuum limit. A peristaltic pump is the pump usually
chosen for surgery of the anterior segment, since it is
inherently safe; it makes it possible to regulate vacuum
and flow separately, generate vacuum only in voluntary
mode with creation of occlusion, and allows fine con-
trol for techniques in the bag, since it creates vacuum
only when the surgeon wants it by occluding the aspi-
ration port (Figures 7-6 to 7-10).
 Fluidics and Machines  93

A B

Figure 7-7. (A–C) Examples of ratios between flow, vacuum,

and rise time for equipment with a peristaltic pump. The flow
C is, respectively, 10%, 50%, and 100% of its maximum value. The
tip is not in occlusion. The fluid that flows in the tubes increases
as the flow increases; the vacuum instead stays constant at zero
(actually, with a sustained flow, a slight vacuum is created in the
aspiration tubes).

much because companies have developed new types of

2. Vacuum pumps include Venturi pumps, membrane
A scroll pump is composed of 2 circular elements: 1 is
stationary and the other moved by an eccentric control
that, run by an electric motor, rotates, making the
mobile part make “orbits” generating a spiral move-
ment. It is also used in other fields of medicine (in
automatic respirators and nebulizers). In eye surgery,
it was initially used by Bausch & Lomb. Its advantages
compared to peristaltic pumps include the fact that the
tubing can be manufactured with very low compliance,
since it does not have to be compressed by rollers: this
makes it possible to reduce the risk of surge. In addition,
the special shape of this pump eliminates the problem
of leakage and consequently reduction of preset aspi-
ration flow rate, which can happen with peristaltic
pumps with high vacuum levels. It is currently not used
pumps aimed at controlling aspiration and infusion
parameters and managing surge (Figure 7-11).4
pumps, and rotary vane pumps.5 The terms come from
direct control over vacuum, while aspiration flow is
regulated indirectly, since it depends on the amount
of tip occlusion, aspiration line diameter, and preset
machine values. The most used model is the Venturi
pump, which operates by means of a flow of gas (air
or nitrogen), which comes through an opening with
various dimensions in a specific cavity connected to
a drainage canister, which, in turn, is connected to
the aspiration line.6 It could be defined as a pressure
converter that can transform air flow at positive pres-
sure into air flow at negative pressure; basically, the
air flow is a controllable parameter and depends on
the amount of compressed air that is added, but the
flow rate no longer is due to different density between
the 2 mediums (ie, the negative pressure is applied to
a tank that collects fluid [air–liquid exchange tank]);
it uses the Bernoulli principle (or Bernoulli effect),
which describes a phenomenon wherein in an ideal
fluid on which work is not done, for every increase in
speed, there is a simultaneous decrease in pressure or a
change in the potential gravitational energy of the flow.
94  Chapter 7

A B

Figure 7-8. (A–C) Examples of ratios between flow, vacuum, and

rise time for equipment with peristaltic pump. With a preset flow
C at 50% and a preset vacuum of 400 mm Hg and with the tip in
occlusion, the vacuum rises in the tubes at a time that is directly
proportional to the flow. At time 0.1 sec, the vacuum remains at
0 mm Hg; after 2 sec, it reaches around 200 mm Hg; and after
4 sec, around 400 mm Hg. Because the tip is in occlusion, no
fluid leaks from the bottle and no fluid reaches the fluid collec-
tion bag.

depends on the speed of the compressed gas injected

Therefore, by exposing the drainage canister full of air
to a gas flow perpendicular to it, a negative pressure is
created, which makes the air flow out of the canister;
from there, the vacuum is transmitted to the aspiration
line, generating a fluid flow. The faster the gas flow,
the higher the vacuum level obtained in the drainage
canister and, consequently, the aspiration level. The
gas speed can be increased, with the same pressure,
by reducing the outflow line (Venturi effect). The flow
rate is proportional to the vacuum level in the exchange
tank and cannot be regulated; the vacuum value
into the system and rarely reaches levels near zero.
It can be controlled with the pedal and, importantly,
remains constant regardless of occlusion/lack of occlu-
sion of the aspiration tip; the rise time depends on
the amount of air in the air/liquid exchange tank and
remains constant if the tank is full of air (Figure 7-12).
In a membrane pump, the vacuum is created by a mem-
brane, which acts on a compensation chamber con-
nected by 2 valves to an aspiration chamber and a dis-
charge chamber. The membrane makes an alternating
back and forth movement by a rod connecting it to a
rotating electric motor. When the membrane is pushed
out, a negative pressure is created in the compensation
chamber: through the opening of 1 of the 2 valves, the
vacuum is transmitted to the aspiration chamber with
resultant drawing in of air from it to the compensa-
tion chamber and liquid from the aspiration tubing
to the aspiration chamber. When the membrane is
pushed inside the compensation chamber, the positive
pressure created is transmitted by the second valve to

A B
C preset at 100% and a maximum preset vacuum at 400 mm Hg
the discharge chamber: the previously aspirated air is
discharged, while aspiration of the fluid stops. Despite
the fact that they are different, the Venturi pump and
membrane pump are functionally similar, since both
reach significant vacuum values without occluding the
aspiration opening on the handpiece. The advantage
Fluidics and Machines  95
Figure 7-9. (A–C) Examples of ratios between flow, vacuum, and
rise time for equipment with peristaltic pump. With the flow
and the U/S tip occluded with the pedal pushed all the way
down, the vacuum rises after 0.5 sec to 100 mm Hg, after 1 sec
to 200 mm Hg, and after 2 sec to 400 mm Hg (vacuum rise speed
200 mm Hg every 1 sec).
obtained is greater capacity to draw the material for
aspiration to the tip; however, at the same time, there is
greater risk of anterior chamber collapse and aspiration
of intraocular structures such as iris, capsule, etc. It is
still necessary for the aspiration opening to be com-
pletely occluded in order to reach the preset maximum
vacuum value. Another difference compared to flow
pumps is the impossibility of independently regulating
the vacuum and aspiration flow rate values, which are
directly proportional to each other.7
The rotary vane pump is composed of a rotor mounted
eccentrically inside a cylindrical chamber; a series of vanes
suspended inside the rotor move freely back and forth, trap-
ping a certain amount of air from the inlet door, which is
compressed and released through an air valve. This contin-
uous motion is used to discharge the air from the drainage
canister where negative pressure was created, which is then
transmitted to the aspiration line (Figure 7-13).8
96  Chapter 7

A B

Figure 7-10. (A, B) Examples of ratios between flow, vacuum, and rise time for equipment with peristaltic pump. With the flow pre-
set to 100%, a vacuum preset to 400 mm Hg, U/S tip occluded and pedal pushed halfway down for position 2 (irrigation/aspiration),
(ie, around half of the preset vacuum) the vacuum after 1 sec rises to 100 mm Hg and after 2 sec to 200 mm Hg.

Figure 7-11. Scroll pump is composed of 2 circular elements:

1 is stationary and the other moves by an eccentric control that,
rotated by an electric motor, rotates making the mobile part
make orbits generating a spiral movement.

Figure 7-12. (A, B) Venturi pump operates by means of a flow of

gas (air or nitrogen), which penetrates though an opening with
various dimensions in a specific cavity connected to a drainage
canister, which is, in turn, connected to the aspiration line.
 Fluidics and Machines  97

REFERENCES
1. Picardo V, Sorce R, Vincenti P. Terminologia della facoemulsifi-
cazione. Focal Point su Chirurgia della Cataratta; Lucio Buratto,
Vittorio Picardo, Fabiano Editore; 2002.
2. Buratto C. Chirurgia della Cataratta. Facoemulsificazione
Evoluzione e Stato dell’arte. 1996:2:365.
3. Aiccer-SOI CATARATTA. Fabiano Editore. 1999;161:2.1.1.
4. Aiccer-SOI CATARATTA. Fabiano Editore. 1999;162:2.1.2.
5. Aiccer-SOI CATARATTA. Fabiano Editore. 1999;163:2.1.3.
6. Aiccer-SOI CATARATTA. Fabiano Editore. 1999.163:2.1.3.
7. Aiccer-SOI CATARATTA. Fabiano Editore. 1999;163:2.1.4.
8. Aiccer-SOI CATARATTA. Fabiano Editore. 1999;164:2.1.5.

Figure 7-13. Rotary vane pump is composed of a rotor mounted

eccentrically inside a cylindrical chamber. A series of vanes sus-
pended inside the rotor move freely back and forth, trapping a
certain quantity of air from the inlet door, which is compressed
and released through an air valve.

Pumps of Newer Machines
Lucio Buratto, MD; Stephen F. Brint, MD, FACS, and Rosalia Sorce, MD
Newer machines have more evolved pumps compared
with the previous generation.1 Some of these include the
simultaneous presence of a peristaltic pump and Venturi
pump with the possibility of switching from one to the
other during surgery. For example, Abbott Medical Optics’s
(AMO’s; Abbott Laboratories Inc) Sovereign WhiteStar
and Zeiss’ new Visalis 500 phaco (Carl Zeiss Meditec
AG) have both pumps. Stellaris with its innovative pump
(Bausch+Lomb Incorporated) has advanced vacuum sys-
tem (AVS) vacuum control (like Venturi), supplied by an
internal compressor, which does not require connection
to a compressed air supply. The aims of the new fluidics
management systems can be summed up as follows: less
ultrasound, increased vacuum, increased flow rate, with
the goal of obtaining greater anterior chamber stability,
constant pressure in the eye, and equal liquid inflow and
outflow. The new machines attempt continuous control of
vacuum, flow, and pump action to always keep the anterior
chamber stable for any vacuum value. They make it possible
to automatically and linearly change phaco energy with
occlusion, pulse, and burst modes. The power pulse is the
pulsed emission of ultrasound starting with low frequency
but can be increased progressively with the pedal until
reaching continuous emission. The burst makes it possible
to emit separate ultrasound bursts with an off-time, which
progressively decreases by pressing the pedal until reaching
continuous emission; it is useful in the first chop steps.
THE ULTRASOUND HANDPIECE
This is the core of the phacoemulsification device. It
is used to break the lens by transforming electricity into
mechanical (or kinetic) energy. It is composed of a motor or
transducer and the handpiece is connected to the panel by
- 99 -
8
a cable. It has an aspiration line, positioned coaxially inside
it and connected by tubing to the pump on the machine.
There is also an irrigation line, connected to the infusion
bottle allowing fluid to flow into the anterior chamber,
maintaining its volume; the aspiration port is located near
the tip so that the fluid comes out of the sleeve. Before start-
ing the operation, it is important to check that the energy
generator is tuned with the transducer in the handle (tun-
ing): this allows the machine to achieve maximum effec-
tiveness; it is like tuning a radio to a station (Figures  8-1
and 8-2).
The fundamental phacoemulsification device functions
are as follows:
Irrigation, from a bottle, hung on a height-adjustable
●
pole, connected to the instrument by tubing that passes
through a pinch valve; the fluid flow is caused by
gravity and the amount of fluid entering the anterior
chamber depends on bottle height, tubing and connec-
tor diameter, and anterior chamber pressure, which in
turn depend on how much liquid is aspirated and any
incision leakage. The height of the bottle usually needs
to be 60 to 70 cm above the patient’s eye even though
some surgeons use heights of 100 to 110 cm; irrigation
is opened using the pedal.
● Aspiration is activated with the pedal in position 2 and
is performed by the pump that creates a pressure dif-
ference between the aspiration line and the anterior
chamber in order to remove a certain amount of fluid
from the chamber per unit of time as described above.
● Emulsification or breaking with ultrasound is per-
formed with the pedal in position 3 and thus with
irrigation, aspiration, and ultrasound activated at the
same time. The ultrasound power is the work (force
per distance) performed per unit of time by action of
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 99-115).
© 2014 SLACK Incorporated.
100  Chapter 8
Figure 8-1. Operation of the phaco system and ultrasound handle.
Figure 8-2. Ultrasound handle: (A) the irrigation line, (B) aspiration line, and (C) electrical connection
are shown.
the ultrasound tip. The disintegrating action of the tip
is mainly performed via a mechanism that requires
mechanical impact of the tip with the lens mate-
rial at the end of each oscillation; bear in mind that
a titanium tip moves by making a forward/backward
movement like a jack hammer and that the penetra-
tion force is closely related to the amount of elongation
and cutting quality of the tip used; currently, emulsi-
fication can be by longitudinal, torsional, or elliptical
movement. Other collateral phenomena including the
generation of sound waves transmitted by the tip, the
impact of liquid and particles pushed forward by the
tip with each oscillation, and a cavitation effect are
insignificant for emulsification of lenticular material.
However, they need to be taken into account because
A
B
C
their incorrect use can cause damage to the wound
both due to heat (burning) and tissue erosion caused by
cavitation. Cavitation is a principle that makes it pos-
sible to understand the phaco tip cutting mechanism.
The tip immersed in a liquid generates compression
and decompression waves through very fast longitu-
dinal movement. The speed depends on the handpiece
working frequency ranging from 28 to 40 KHz. When
the stroke is reached, an acoustic cavitation phenome-
non starts. During vacuum, a multitude of gas-bubbles
are created in the fluid, which become larger as long
as the negative pressure lasts: this phenomenon is the
beginning of cavitation (ie, the formation of gaseous
cavities within a liquid). During the ultrasound com-
pression phase, the enormous pressure on the just

expanded bubble compresses it enormously, increasing
the temperature of the gas in it; the gaseous bubble
collapses on itself imploding with a consequent release
of impact energy. This energy strikes the lens surface,
disintegrating the tissue. The cavitation process con-
centrates energy in tip vibration and releases it in the
form of movement and collapse of the bubbles. There
is a threshold phenomenon below which cavitation is
not generated. By increasing the oscillation frequency,
the amount of generated cavitation energy is increased
until obtaining 40% more acoustic energy.
The energy is transmitted in front of the tip in a cone
shape; thus, it is important to correctly aim the tip during
emulsification in order to prevent energy from radiating
toward nonlenticular structures such as the margin of the
capsulorrhexis, iris, endothelium, and posterior capsule.
The ultrasound power for every device is expressed as a
percentage compared with the maximum obtainable. The
ultrasound percentage to use in a certain step of the sur-
gery depends on the instrument characteristics and needs
to be selected based on cataract type or nucleus hardness.
Ultrasound activity can occur in 3 ways:
1. Cutting or shaving: The tip shaves the lens and is occu-
pied by lenticular material not exceeding more than
one-third of the aspiration lumen.
2. Sculpting: The tip enters the lenticular tissue by half or
two-thirds of the aspiration lumen (sculpting).
3. Occlusion: The tip is positioned so that the lumen is
completely occupied by lenticular material: with a
short ultrasound burst, the material is engaged by the
tip and is held to it with suction; with this maneuver,
the tip can move the material or stabilize it to provide
sufficient resistance to another instrument.
TRANSDUCERS
These are devices, which, by changing their length in
response to an electric field, convert alternate voltage sup-
plied by the ultrasound management circuit board into
mechanical vibrations. The power they express depends on
2 variables: elongation and frequency. Elongation or stroke
is the maximum length of forward/backward movements
made by the tip that moves on its longitudinal axis via the
mechanical energy produced by the transducer; gener-
ally, this is between 70 and 120 μm and can be changed
by the surgeon by using the power rate function and can
be controlled linearly by increasing pressure on the pedal.
The frequency represents the number of complete forward/
backward movements, which the phaco tip makes in the
unit of time, thus determining the movement speed of
the tip. This may be between 20,000 and 43,000 cycles a
second (20 to 43 KHz) or within the ultrasound field. In
traditional phacoemulsification, the power values range
from 60% to 80% in the initial steps and from 40% to 50%
Pumps of Newer Machines  101
in the second step, that is, as the nucleus becomes smaller.
These parameters can vary greatly based on the machine
type, cataract type, and technique the surgeon wants to
use. There are 2 types of transducers: magnetostrictive and
piezoelectric; the latter transducers are those currently used
and are composed of shaped ceramic disks that vibrate at a
certain frequency when subjected to an alternating electric
field; they are lighter and easier to use than magnetostric-
tive ones and their structure has made it possible to obtain
coaxial use of the aspiration line and greatly reduce the
outer handpiece diameter.
ULTRASOUND
Ultrasound mode: The use of power can be continuous,
pulsed, or burst: the first one represents the standard; the
second allows a gentler and progressive fragmentation of
lenticular material by the tip, and it is useful in soft nuclei,
to aspirate nucleus near the posterior capsule and in the
final fragmentation steps when it is necessary to remove the
final remnants and prevent deep oscillations in the anterior
chamber; and the third makes it possible to remove nuclear
fragments faster and more efficiently.
Thermal effect: The transformation of energy from
one form to another always involves a dispersion that
generates heat: the change from electromagnetic energy
to sound energy and then mechanical causes heating of
the ultrasound handpiece components that are cooled by
infusion and aspiration fluid. If the flow is significantly
reduced during fragmentation or if occlusion occurs fre-
quently, there may be an increase in tip temperature, which
can cause damage, possibly significant, to the incision.
Consequently, when high ultrasound power needs to be
used for a long time, adequate flow for cooling the tip needs
to occur (Figure 8-3).
Tip
The tip is placed at the distal end of the handpiece and is
connected to the transducer by threading; it is made of tita-
nium, which allows high resistance to the strain it is sub-
jected to. The aspiration port is always located at the distal
end, while the angulation is variable and may be 0, 15, 30, or
45 degrees, and its action occurs as a “jack hammer” effect
in traditional phaco. A 15-degree tip has better occlusion
capacity, a 45-degree tip has better cutting ability, and a
30-degree tip is an excellent compromise. The tip is covered
by a silicone sleeve that isolates and protects the sclerocor-
neal tissue from heat and mechanical injury caused by the
ultrasound; it also allows irrigation flow through the distal
opening and 2 side holes.
Manufacturers currently tend to offer tips with increas-
ingly smaller diameter, high cutting ability, and less ten-
dency to cause corneal burns (which mainly depends on
other machine characteristics).
102  Chapter 8

Figure 8-3. The phaco tip is positioned at the distal end of the handle and is connected to the
transducer by threading; it is composed of titanium, which allows high resistance to the strain it is
subject to. The aspiration mouth is always located at the distal end while the angulation is variable
and can be 0, 15, 30, or 45 degrees.

A A

B
Figure 8-5. (A, B) The phaco tip: The 30-degree tip is an excel-
lent compromise between the 15-degree tip with better occlu-
sion capacity and 45-degree tip with better cutting ability.

The so-called micro tips have an outer diameter of

Figure 8-4. (A, B) The phaco tip: The 45-degree tip has better
cutting ability.
Other than traditional tips, the following are available:
● Tips with different angulations; tip with zero degrees
for phaco chop
● Anticavitation tips that reduce the presence of air
bubbles due to turbulence during oscillation
● Tips with double angulation/15 to 60 degrees (Kratz
turbo tip) to increase cutting ability without sacrificing
occlusion capacity
● Narrow tips (Shimizu) used to easily obtain occlusion
and use vacuum to manipulate the nucleus
● Elliptical tips (Epsilon)
● Angled tips (Kelman) to increase fragmentation
capacity.
0.9 mm (1.1 mm in standard tips) and an internal lumen
between 0.5 and 0.7 mm (0.9 mm in standard tips). A reduc-
tion in dimensions leads mainly to 2 advantages: the possi-
bility of entering the anterior chamber through increasingly
small incisions and the reduction of passive flow at the time
of occlusion break with consequent better anterior chamber
stability. The disadvantage is lower nuclear fragment aspi-
ration ability, which can be partly offset by increasing the
vacuum levels. The search for maximum cutting efficiency
has led to the development of different shaped tips, for
example, flared and Kelman tips with an inclined axis and
lower inner diameter. They have better respect for the cor-
neal tunnel and contribute to greater anterior chamber sta-
bility and better fluidics. Other tips are also equipped with
aspiration bypass system (ABS), a compensation system,
which works during occlusion to reduce anterior, chamber
spikes and ensures constant flow and adequate tip cooling
with reduction in heat stress. Flared tips are used to obtain
better contact between the tip and lenticular material, with
the advantage that the narrowing right under the opening
creates an increase in aspiration force making it easier to
grasp and hold the lenticular fragment (Figures 8-4 to 8-6).
 Pumps of Newer Machines  103

Figure 8-6. (A, B) The phaco tip: The tip at 0 degree for better
occlusion capacity is suitable for the phaco chop. The occlusion
does not depend on the tip angulation but is created when
the surface of the fragment to aspirate is parallel to the tip
angulation.

Pedal
The pedal is used to activate all of the phaco machine
functions and thus control fluidics; it can be set to man-
age surgical functions in fixed or linear mode: aspiration,
Figure 8-7. Alcon’s Infiniti phacoemulsification machine.
vacuum, and power; if linear control is present, it is pos-
sible to increase the amount of the function within the set
limits simply by increasing pressure on the pedal. It has
4 positions divided into 3 thresholds (Figures 8-7 to 8-9):
● Position 0 (zero): Standby position, that is, the pedal is
not pressed.
● Position 1: This is the first click after the pedal is
pressed; by opening the pinch-valve, it creates irriga-
tion by gravity which is proportional to the infusion
bottle height, tubing diameter, and its connectors, as
well as intraocular pressure; in the presence of wound
leakage, this function is used to cool the tip and
keep the anterior chamber stable. All current phaco-
emulsification devices are equipped with continuous
irrigation function, which helps those just starting to
operate since it eliminates an additional control ele-
ment, that is, position 1, by keeping the pinch-valve
constantly open, but it may be counterproductive in
cases of capsular dehiscence. It is important to stay in
position 1 when nuclear material is manipulated as well
as during nucleus rotation in order to allow the infu-
sion flow to maintain the architecture of the anterior
chamber and capsule.
● Position 2: It causes activation of the aspiration pump,
maintaining the irrigation function at the same time;
an increase in aspiration flow corresponds to reduction
104  Chapter 8
Figure 8-8. B&L’s Stellaris phacoemulsification machine.
in vacuum rise time; the aspiration flow stops when
the tip is occluded and if the pump continues to run as
vacuum increases. Latest generation phaco machines
allow linear vacuum control with the possibility of
memorizing 2 different aspiration flows in pedal posi-
tion 2 or 3 or to change the aspiration flow based on
the desired vacuum: these features make it possible to
decrease chamber collapse.
● Position 3: In addition to irrigation and aspiration,
ultrasound is activated, whose power is expressed as
a percentage compared with the maximum obtainable
value; linear control is possible.
The pedal can also be used to activate some additional
phaco functions such as pulsed or burst mode (Figures 8-10
to 8-12).
SETTINGS
Each company recommends settings for individual
machines in order to make the fluidics systems effective
and safe. They are designed with handpieces and tubing
and have very precise characteristics. However, surgeons
have the opportunity and responsibility to change these set-
tings to increase functionality in various surgical circum-
stances. The understanding of the nuances mainly comes
with surgical experience; however, knowing a few basic
principles is essential.
The infusion should be sufficient for maintaining the
anterior chamber volume proportionally to the change
in outflow. The height of the bottle normally needs to be
increased with an increase in aspiration flow and for larger
incisions. The high flow used in current phaco is accept-
able with a controlled outflow system. Despite the fact that
high flow increases the movement of nuclear material and
potentially the iris and capsule, it is useful for cooling the
phaco tip and preventing tunnel burns.
Surgeons in training should use low flow in order to slow
down anterior chamber movements.
The height of the bottle must be assessed with pump
operation and with the amount of occlusion so that there
is equality between infusion and outflow. The same con-
siderations are valid for surge. Sculpting of the nucleus
can be done with low vacuum, since the nuclear material
is stabilized by the zonules and capsule; the flow should be
approximately 20 cc/min. During removal of the nuclear
fragments or quadrants, the vacuum and flow need to be
higher, especially for hard cataracts, in order to reduce the
tendency of ultrasound to move the material away from
the phaco tip. The basic settings are 30 cc/min of flow and
200 mm Hg of vacuum for a reasonable starting point. For
chopping, a similar flow with 300 mm Hg of vacuum is a
compromise between an acceptable rise time and a safety
margin against surge.
High vacuum may be necessary for grasping and manip-
ulating the nucleus. Surge occurs when a fragment occlud-
ing the tip is suddenly aspirated by high vacuum normally
after the fragment has been emulsified: the tubing collapses
when the vacuum increases, and as soon as it constricts,
it suddenly opens causing a surge of fluid in the infu-
sion line. This situation may cause a partial collapse of
the anterior chamber and undesired forward movement
of the posterior capsule. The following is recommended
to minimize this surge effect: use a low vacuum and low
aspiration and increase infusion by raising the bottle; use
a phaco tip that has a small opening or aspiration bypass
which permits slight flow when the tip is occluded; work
 Pumps of Newer Machines  105

Figure 8-9. AMO-Abbott’s WhiteStar Signature phacoemulsification machine.

Figure 8-11. Phaco in I/A function: Pedal position and cor-

Figure 8-10. The 3 possible positions of the phacoemulsifier
responding functions irrigation and then irrigation/aspiration.
pedal.

with phaco devices that have more rigid aspiration tubing,

so intrinsic resistance to the flow of aspirated material in
the tube mitigates the collapse. Companies currently have
microprocessors, which modify the surge by detecting flow
restoration after occlusion and with immediate lowering
of vacuum by slowing down or reversing the pump. High
vacuum, that is, over 300 mm Hg, can easily be used when
using equipment, which allows surge control. High linear
vacuum is useful during irrigation/aspiration (I/A) in order
to bring the cortex into the center of the anterior chamber
and then draw it inside the aspiration opening.
Rise time is the interval between occlusion of the phaco
Figure 8-12. Phaco in ultrasound function: The 3 pedal positions.
or I/A tip and reaching the preset maximum vacuum value;
it is regulated by presetting the flow in the peristaltic or
flow pump. Even if there is no flow when the tip is occluded,
106  Chapter 8
the aspiration flow setting regulates pump speed. Doubling
the flow rate halves the rise time. In some systems (eg,
INFINITY), the rise time can be modified by a presetting
where the machine senses an increase in infusion line pres-
sure and increases the vacuum (indicating occlusion) and
then changes the pump speed by increasing or decreasing it
based on the surgeon’s decision.
Even phaco parameter setting indirectly affects the
fluidics and helps improve efficiency. When approaching
cataract surgery, the first aim is to “avoid trouble” and
reduce the time inside the eye to a minimum. With experi-
ence, this aim is fine tuned to “perform a clean operation
with a minimum use of resources.” Phaco machine setting
is the key time for making phacoemulsification smoother
and more efficient. Efficiency means complete removal of
the nucleus and epinucleus using low ultrasound powers
with short time. Each surgeon develops his/her own setting
for each phaco step. During sculpting, all the parameters
(ultrasound, vacuum, aspiration) are kept within an aver-
age range because the nucleus is a “big piece” at this time,
and a high aspiration value could cause excessive move-
ment toward the tip; instead the focus is on emulsification
of a small part and optimal movement of pieces toward the
phaco tip. Aspiration is set as high as needed to engage the
nucleus and hold it. The ultrasound power is high to be able
to emulsify and let the tip move in the nuclear material at
the same time. The vacuum is set just slightly high to hold
the fragment. The phaco power indirectly affects fluidics,
since it breaks the nuclear material so it can be aspirated;
it tends to repulse it away from the phaco tip and conse-
quently tends to increase the flow. Low ultrasound power
values let the aspiration flow draw the material toward the
tip and partly or completely occlude it, and thus reduce or
block the flow. Vacuum, normally preset in phaco mode,
varies based on the degree of rise time occlusion.
Occasionally, undesired material may come into contact
and thus occlude the phaco tip or I/A handle and risk being
aspirated: modern machines are designed with a venting
system that can be used to stop the vacuum by returning to
the pedal zero position.
Regardless of the technique used (divide and conquer or
chop) to remove nuclear fragments, aspiration needs to be
fairly high. The nuclear section that is already mobilized by
hydrodissection and cracking must move efficiently toward
the tip where it will be emulsified with a minimum amount
of phaco energy. A high vacuum makes it easier to remove
emulsified fragments. The surgeon has 2 choices: burst or
pulse mode. Both have parameters and settings similar to
aspiration, ultrasound power, and vacuum, but they are
significantly different in terms of management by the sur-
geon. Ultrasound power is used in energy “packets” that the
surgeon controls.
These are the basic principles useful for anyone starting
surgical training and knowing them helps to understand
and later personalize the settings to safely and efficiently
remove the cataract.
Phaco machines emit sound signals, which are useful
during the operation:
● Vacuum sound, which varies, based on the amount of
vacuum; it can be lowered but not turned off.
● Occlusion sound indicates that the vacuum is the same
as or near the preset limit and the aspiration flow is
reduced or stopped to prevent exceeding the limit.
● Sound of I/A during occlusion.
MACHINES
The aim of companies is to produce new phacos that
have Venturi-like performance for all pump types via new
software programs but maintain the safety and reliability
characteristics of peristaltic pumps.
WhiteStar Signature From
Abbott Medical Optics
Microincision cataract surgery (MICS) would not be pos-
sible without the advances in ultrasound power modulation
introduced for the first time with the WhiteStar Sovereign
from AMO. The introduction of WhiteStar’s cold phaco
technology in 2001 made it possible to change the duration
of the period of pulses and standby independently in order
to reduce the risk of wound burns, use less phaco energy,
and consequently effective phaco time, turbulence, and
chattering of nuclear material. There is less damage to the
trabecular meshwork and endothelium, which translates
into minimum postop pressure spike, improving follow-
ability. Additional features were introduced with the second
generation of micropulse technology, that is, WhiteStar
ICE (increase control and efficiency), which includes duty
cycle control (which consists of a period of energy followed
by a standby period) with the pedal to improve effective-
ness for hard nuclei, advanced formation of pulses, and
chamber automated stabilization environment algorithm
known as CASE. CASE significantly reduces postocclu-
sion surge by automatically controlling the vacuum curve;
it constantly monitors the anterior chamber, recogniz-
ing occlusion before it occurs and consequently reverses
the pump, reducing the vacuum to levels predetermined
before the occlusion break occurs. The latest generation of
AMO’s phaco system is WhiteStar Signature where existing
technology has been advanced. The fusion fluidics include
both the regulation algorithm for the CASE vacuum and
the automatic adaption to the aspiration setting and phaco
power. It is characterized by the use of 2 pumps, peristaltic
and Venturi. Compared to earlier machines from the same
company, it has optimized ultrasound emissions, thanks to
 Pumps of Newer Machines  107

Ellipse technology, introduced in 2008, which uses elliptical

tip movement, making cutting easier and more efficient; it
has improved parameter management with the non-zero
start point, an option that lets the surgeon best use the
pedal stroke allowing the benefits of linear settings with
panel ones (each movement on the pedal is used to man-
age a small group of settings) for aspiration, vacuum, and
ultrasound values usable both with Venturi and peristaltic
pumps; it has been designed to increase efficiency and
improve system response; it permits faster response times
for aspiration, vacuum, and ultrasound with more precise
fluidics control in the same movement range. The vari-
able vacuum rise time increases the Venturi pump control,
makes it possible to work with “reduced” vacuums and
select the speed for reaching the preset maximum vacuum
level; setting options range from 1 to 5: the lowest settings
(1 and 2) are closer to the behavior of a peristaltic pump,
setting 3 or 4 is better suited to surgeons using Venturi
pumps because it permits greater “reactivity” and makes
the machine flexible and adaptable to various surgical
requirements. The cold phaco technology is a patented
software application that has changed the characteristics of
phacoemulsification by modifying heat effects and allow-
ing control of all types of lenses without reducing cutting
effectiveness. The system creates energy at the tip for short-
time intervals, producing a microburst heat effect with the
following advantages: 1) lower total energy released given
the on-off emission; 2) lower temperature increase: inertia
and dissipation keep the tip area reasonably cold (Figure
8-13).
The new Ellipse FX technology boasts of a high cut-
ting frequency of 38 KHz (the frequency is the number
of forward/backward or sideways movements recorded in
a specific period of time and expressed in cycles per sec-
ond), which means 45% faster compared with the previous
generation and an extended stroke (physical forward/back-
ward or sideways movement of the tip). It works with both
straight and curved tips and the surgeon can easily adapt it
to use any technique. The combination of longitudinal and
transverse movement for sculpting the groove, impacting Figure 8-13. AMO-Abbott’s WhiteStar Signature phacoemulsi-
the lens in more than 1 direction, ensures and facilitates fication machine.
more efficient cutting with travel 3 times broader than just
longitudinal ultrasound; it reinforces control by improving
followability and uses less energy, lower quantity of fluids, infused balanced salt solution (BSS) during the operation;
shorter surgical times, and consequently improved fluidics. an increase in flow corresponds to an increase in the speed
The tip moves in the lens like a “warm blade in butter,” that at which these events occur within the eye; an integrated
is, a constant cut is obtained with a perfect mix of elliptical and efficient management of the fluidics increases safety,
and longitudinal energy; this translates into better follow- reduces the surge effect, and improves phacoemulsification
ability, that is, less tip material repulsion: nuclear fragments effectiveness.
remain on the tip opening and chattering phenomena are When should a peristaltic pump be used and when
decreased that cause the production of microfragments should a Venturi pump be used?
resulting in mist and turbulence. The presence of 2 pumps The former is ideal for loose zonules, for pseudoexfolia-
at the same time, called fusion pump technology, is impor- tion, and in the presence of floppy iris. Vacuum and flow
tant because the flow and vacuum level contribute to are 2 separate values, that is, the surgeon can decrease the
supplying the force to aspirate the fragmented lens and vacuum rise time without decreasing the ability to hold the
108  Chapter 8
nucleus fragment on the tip. The Venturi pump is charac-
terized by a correlation between flow and vacuum: a lower
aspiration level corresponds to lowered ability to hold the
nucleus fragment on the tip.
The selection needs to be made based on the cataract
first, then on the surgery. For example, for removal of
the epinucleus, use of a peristaltic pump combined with
non-zero start point can be considered. A peristaltic pump
increases and improves control, and a Venturi pump
increases efficiency. When a peristaltic pump is used to cre-
ate vacuum, the aspiration line needs to be occluded: if there
is no occlusion, fluid is aspirated minimally and sufficient
vacuum is not created; if there is occlusion, the aspiration
is circumscribed and a high vacuum is created. With occlu-
sion, the vacuum increases and reaches the desired level
quickly increasing the flow. This pump is designed to allow
high fluidic control; flow and vacuum can be separately and
independently regulated; by changing these parameters, the
surgeon can decide the speed for performing things during
surgery; it keeps the chamber very stable and ensures good
holdability during the quadrant removal phase.
The Venturi pump uses the Venturi effect, that is, aspi-
ration of the air from an opening based on the vacuum;
this condition creates a different pressure between the air
contained in the tubing and that in the drainage canister:
this pressure difference creates the vacuum to remove the
fluid from the aspiration tubing, and the vacuum is thus
generated instantaneously so that it is immediately avail-
able as soon as the pedal is activated. The high vacuum
is automatically correlated to a high aspiration value. The
resulting advantage is the perception of a very efficient and
dynamic surgery. It works very well even when occlusion
is difficult (thin tissue or very small nuclear fragments); it
has excellent followability (the fragments are drawn toward
the tip), minimal fragment repulsion, and low chattering;
the vacuum rise time is very fast and corresponds to high
effective aspiration.
In summary:
Peristaltic pump:
1. It requires occlusion to generate vacuum.
2. Vacuum and flow can be managed separately.
3. It ensures maximum fluidic control.
4. It provides a stable chamber.
5. It offers excellent holdability during the quadrant
removal phase.
6. It provides excellent fluidic control.
Venturi pump:
1. Vacuum is always present regardless of occlusion.
2. The vacuum is generated instantaneously when the
pedal is activated.
3. The rise of vacuum speed is very high with significant
aspiration values.
4. It provides high efficiency.
5. The fragments are drawn toward the tip.
6. It contributes to excellent followability, low chattering,
and minimal repulsion.
It also has new software used for a gentler emission of
phaco power between 0% and 15%, a sovereign style reflux;
that is, when the pedal is lifted, the irrigation line remains
open after aspiration is completed.
The recommended parameters for a routine operation
are as follows: 20 mm Hg vacuum, 24 cc/min flow with
60 cm bottle height and 80% to 90% ultrasound (with
linear control) during sculpting; 320 mm Hg vacuum, 28 to
30 cc/min flow with 90 cm bottle height and use of micro-
pulse (or elliptical movement) in phase 2. To conclude:
WhiteStar Signature:
1. It offers better ultrasound management: Ellipse FX
uses a longitudinal and transverse movement at the
same time for an easier and more efficient cut.
2. It works with both straight and curved tips.
3. It uses a 45% higher frequency and a stroke 3 times
greater.
4. It offers improvement compared with previous
machines for parameter management: the non-zero
start point combines the characteristics of linear and
panel parameters, the variable vacuum rise time adds
5 different control levels for users of Venturi pumps.
5. ICE technology represents further progress, since it
combines modulated ultrasound power with vacuum
control via application of the CASE (chamber stabiliza-
tion environment) system whose benefits can be sum-
marized as follows:
a. Micropulses of energy separated by short periods of
tip cooling
b. Less energy emitted inside the eye, reduction of
injury to the cornea, and incision due to high
temperatures
c. The cold energy permits a smaller incision and bet-
ter equilibrium of the anterior chamber
d. Reduction of anterior chamber turbulence
e. High followability
Stellaris From Bausch & Lomb
This is the pioneer of the microincision. The evolution
of phaco techniques, in terms of incisions from 3.5 to 2 mm
has led to a series of changes, regarding fluidic control,
chamber stability, optimization of ultrasound power, and
reduction of heat risk (ie, wound burn). Currently, cataract
surgery with 1.8-mm coaxial microincision seems to be the
technique to adopt. The positive aspect is the short learn-
ing curve and compatibility with fluidic settings that each

surgeon is familiar with; in addition, it is useful for small
pupils. Intraoperative floppy iris syndrome (IFIS), pseudo-
exfoliation, or for zonule or capsule breaks. Unlike MICS
(B-MICS), C-MICS uses the sleeve, which reduces leakage,
improves anterior chamber stability, and protects the cor-
nea from friction. In addition, the nondominant hand is not
involved in an “active” manner to maintain the infusion.
Thanks to the EQ fluidic management technology used,
this phaco machine offers perfect fluidic equilibrium with
subsequent high chamber stability during all surgical steps
and with different techniques used including using high
vacuum required by the newest procedures. Normally, the
equilibrium between infusion and outflow is maintained
but the situation becomes risky in postocclusion surge,
which occurs when the occluded phaco tip suddenly aspi-
rates a piece of nucleus, and, consequently, the quantity
of aspirated liquid depends on various factors including
the inner diameter of the tip and aspiration tubing which
determine the resistance to outflow, tube compliance,
that is, “rigidity,” and the differential pressure when the
tip is occluded (differential pressure means the differ-
ence between the positive intraocular pressure in relation
to bottle height and the negative pressure inside the tip
determined by the vacuum level generated by the pump).
The volume of fluid aspirated during the surge needs to
be replaced by infusion, otherwise the anterior chamber
collapses. The fluidic changes increase with an incision
less than 2 mm, since the smaller diameter of the infusion
instruments allow a release of fluid per second lower for
each bottle height. To overcome this limitation, the alterna-
tive is to use a higher bottle height to increase the potential
infusion volume per second. Some surgeons propose put-
ting the bottle at 150 cm, but the problem is that intra-
ocular pressure is directly proportional to bottle height and
inversely proportional to outflow. In addition, every time
aspiration stops because the tip is occluded or the surgeon
returns to pedal position 1, the intraocular pressure (IOP)
depends only on the bottle height. BSS produces around
0.73 mm Hg of pressure for each cm in height; if there is
no outflow, a height of 150 cm produces 100 mm Hg of
intraocular pressure. And this is only 1 part of the problem;
as soon as aspiration returns, the IOP reduces proportion-
ally to outflow. During surgery, the phaco tip alternates
continuously between occluded and nonoccluded states:
this can create significant IOP spikes, which can produce
stress or traction on the macular capillaries, choroidal ves-
sels, vitreous, and other intraocular structures. Another
alternative to increase infusion during a microincision is to
pressurize the bottle with an air pump. The first air pump
for cataract surgery was inserted in the first phacoemulsi-
fication prototype designed by Charles Kelman and Anton
Banko. Bausch & Lomb has currently added an air pump to
Stellaris. In addition, this machine possesses a handpiece
with an infusion channel, which releases more BSS per
second at every given bottle height; the tubes have been
Pumps of Newer Machines  109
built with a large diameter, with high compliance (soft)
infusion line and a small diameter and a low compliance,
that is, rigid, aspiration line. This combination optimizes
the BSS release capacity, stabilizes the chamber, and mini-
mizes postocclusion surge for a vacuum over 300 mm Hg.
It has a stable chamber, that is, a microfilter positioned near
the handle that holds nucleus particles larger than 0.5 mm
preventing undesired aspiration line occlusions. The inner
tube diameter is differentiated and helps all surgical steps:
in the initial portion, it is 1.5 mm and permits aspiration
at high flow values (400 mm Hg = from 100 cc/min), and
then reduces to 0.9 mm with consequent limitation of the
aspiration flow quantity (400 mm Hg = to 40 cc/min); this
makes it possible to work with high vacuum (high frag-
ment grasping and holding capacity—less repulsion) with
maximal chamber stability. The microfilter and smaller
diameter aspiration tube create greater holdability with
lower flow. Therefore, a reduction of postocclusion surge is
obtained at high vacuum values, with consequent reduction
of all the critical factors to consider when performing MICS
phaco techniques. It also permits fast nuclear emulsifica-
tion and fragment removal made easier by efficient cutting
dynamics. It boasts advanced ergonomics and easy use. The
Stellaris pump technology has been completely redesigned
and includes the stable chamber fluidics module, which
provides more precise vacuum control compared with
previous pumps (ie, the Venturi pump). It is electric and
offers the advantage of eliminating the need for external
compressed gas. The system uses 2 sensors, which provide
feedback to the computer at the same time; 1 sensor moni-
tors the pump speed and the other controls the vacuum.
The 2 sources of information are then processed by the pro-
portional–integral–differential, an algorithm commonly
used in jet control systems. Another progress in Stellaris
fluidics is a dual linear wireless, Bluetooth pedal; it has a
variety of programmable options. By combining the phaco-
emulsification with vitrectomy, Stellaris has a flexible and
complete instrument, different from the others currently on
the market (Figure 8-14).
Features
1. Possibility of dual linear control for flow and/or vac-
uum; for example, the first can be selected for the
sculpting phase and the second for the nuclear and
cortex removal steps and for cleaning the capsule; in
flow mode, it controls vacuum levels in real time; in
vacuum mode, it measures and manages the vacuum
with extreme precision in order to provide high, and
above all predictable, performance, to reduce postoc-
clusion surge effects ahead of time. Following the loss
of occlusion, Stellaris regulates the vacuum in the aspi-
ration line, stabilizing the anterior chamber, improving
safety and control.
110  Chapter 8
Figure 8-14. B&L’s Stellaris phacoemulsification machine.
2. Handpiece that works at 28.5-KHz frequency, with
ultrasound available in continuous, pulse, and burst
modes.
3. Possibility of performing noninvasive cataract surgery:
microcoaxial with 1.8- or 2.2-mm incision (dedicated
tip and sleeve), 2 handed.
It is innovative because it possesses an AVS (Venturi
type) vacuum control pump run by an internal compres-
sor, which does not require connection to a compressed
air source. The resulting advantage is an optimization of
parameters (ie, an increase in the vacuum level and a sig-
nificant reduction in ultrasound time).
Basically, EQ fluidics technology provides an equilibrium
of aspiration dynamics both in vacuum control and flow
control modes supplying solid chamber stability during the
entire procedure, especially with unequalled followability
and aspiration control, minimal postocclusion surge, and
excellent holdability.
The Stellaris project originated from a need to offer sur-
geons the opportunity of performing new techniques using
the fluidics they prefer (fluid vacuum).
Figure 8-15. Torsional and longitudinal movement.
The EQ system makes it possible to customize Stellaris
system fluidics based on needs: by selecting the EQ-vacuum
fluidics module in combination with stable chamber, tub-
ing performance, better than Venturi, can be obtained.
A few of its strong points are as follows:
● Greater followability and maximum aspiration control
● More precise and predictable control of vacuum
response
● High vacuum levels with exceptional aspiration flow
stabilization for MICS techniques
● Extraordinary stability of the anterior chamber during
surgery for maximum safety and predictable perfor-
mance: no external air source or other compressed
gases
Infinity From Alcon
It possesses 3 different functions for lens emulsification:
AquaLase, Ozil, and ultrasound. AquaLase uses a BSS jet,
which is reflected at 57 degrees by the tip by a soft tip; it is
a procedure that is slowly being abandoned.2–7
Traditional phacoemulsification uses a forward and
backward longitudinal movement to improve entrance of
the material inside the tip. This new machine relies on a tor-
sional movement, which cuts and removes the lens because
of continuous shearing action. The longitudinal movement
helps push the material into the tip, shearing cuts and
removes better and continuously. The transverse cutting–
shearing action of Ozil makes it possible to remove material
in all movement phases and not just while advancing like

TABLE 8-1.
DIFFERENCE BETWEEN MAJOR COMPANY HANDPIECES
Ellipse Fx̶Abbott Ozil IP̶Alcon
Handpiece frequency: 38 KHz Handpiece frequency: 32 KHz
Works simultaneously with elliptical Works with torsional and
and longitudinal movements, with longitudinal movement best with
straight or curved tips curved tips
Compatible with MICS technique Not compatible with MICS
technique
with traditional ultrasound. The action is optimized using
the Kelman tip, which is the best selection due to its shear-
ing action and wide stroke (elongation). The new Ozil 12 tip
is characterized by a 12-degree angulation compared with
the 22-degree angulation of a traditional tip. There is also
the Akahoshi version, with smaller angulation, which
makes the direct chop technique easier (Figure 8-15).
The advantages of using Ozil are as follows:
● Greater efficiency: Due to the absence of repulsion,
minimal turbulence, reduced heat emission, and last
but not least reduction of the BSS used, the high emul-
sification efficiency (in particular of the 45-degree
mini-flared tip) makes it possible to sculpt even the
hardest nuclei with shorter operation times and less
dissipated energy regardless of the chosen technique:
the result is less overall inflammation of the anterior
segment and less stress on the endothelium.
● Increased followability, which makes it possible to
reduce the fluidic parameters maintaining surgical
efficiency with consequent reduction of stress on the
zonules. One of Ozil’s further refinements is Ozil
IP (Intelligent Phaco) (ie, “intelligent” management
of phaco energy). During surgery, the eye is left in a
more natural state, with less occlusion, less instabil-
ity (surge), and fewer intraocular pressure spikes. To
obtain the maximum benefits from torsion, the phaco
tip must not be in complete occlusion; since it would
lose the physical cutting plane, followability would
be reduced, with consequent repulsion of the cataract
lens fragments. Ozil IP has simply eliminated this
condition by maintaining the cutting plane always in
view, continuously exposing the material to transver-
sal emulsification action of the torsional procedure,
distributing a very small quantity (by short pulse) of
longitudinal ultrasound right before complete occlu-
sion. IP is activated only when a specific vacuum limit
threshold is reached: at this point, Ozil IP intelligently
adapts energy distribution with a micropulse of tradi-
tional ultrasound.
For hard cataracts, Ozil IP makes it possible to use less
energy without using vacuum, and high flow, less BSS can
Pumps of Newer Machines  111
STELLARIS from Bausch & Lomb
Handpiece frequency: 28.5 KHz
Work only with longitudinal
ultrasound, with straight tips
Compatible with MICS technique
be used with resulting lower turbulence in the anterior
chamber and better control of the material always posi-
tioned in front of the tip, which means more safety for the
capsule and endothelium.
Basically, Ozil IP does the following:
● Improves emulsification by maintaining and repo-
sitioning the material on the shearing plane without
introducing repulsion.
● Increases followability by never allowing the vacuum
to reach the preset maximum value.
● Leaves the eye in a more natural state. It decreases IOP
spikes by reducing surge and postocclusion surge.
Ozil microcoaxial incision size is minimal, it reduces
postop astigmatism; since it “respects” the tunnel mini-
mizing thermal injury, it shortens the time within the eye,
provides greater anterior chamber stability, and reduces
turbulence and use of BSS, and consequently, it permits bet-
ter management of complicated cases. In addition, shearing
is more efficient than the jackhammer effect of traditional
ultrasound, since it does not cause repulsion: with torsional
movement, the phaco tip does not just move “toward” the
lens but also “within” it and induces one-third of the heat;
there is 50% less movement at the incision. It makes it pos-
sible to leave the tip in the center of the anterior chamber,
with consequent fewer manipulations within the eye, and
lens fragments, if not held by an insufficient cracking, move
by themselves toward the tip; they need to be chopped and
freed before moving them.
Recommended Parameters
Continuous sculpting torsional, vacuum at least 70 mm
Hg or higher, torsional amount up to 100%, customized
pulsed chop; continuous torsional or customized pulsed
quadrant removal: 30 cc/min, 300 mm Hg, and 75 to 90 cm
bottle. Vacuum and flow are preferable during the chop
or quadrant removal. Linear flow (with a minimum of
10–30 cc/min) and linear vacuum need to be programmed
for the epinucleus program. Clogging (obstruction of the
tip by lens material) occurs when the best tip is not used,
or due to insufficient use of Ozil width; to avoid this, a
45-degree mini-flared tip should be used and shorten pedal
position 3% to 20% (Table 8-1).
112  Chapter 8
Figure 8-16. Centurion, the new Alcon phaco
phacoemulsification machine.
Practical Tips for Solving Some Frequent
Problems
1. Inadequate infusion with unstable anterior chamber:
a. The bottle does not have an air intake.
b. The bottle is empty.
c. The bottle height is too low as compared to the
patient’s eye.
d. The infusion line is bent.
e. The fitting with the handpiece is missing.
f. The incision is too small.
g. Movement of the handpiece compresses the infu-
sion sleeve.
h. Too much visco in the anterior chamber.
i. Too much outflow.
2. Impossible to aspirate and hold nuclear material on the
phaco tip—possible causes:
a. Phaco power pushing too high the material away or
creating too much space within the nuclear frag-
ment, preventing occlusion.
b. Vacuum setting too low: Except for in a Venturi-like
system, increase in vacuum has a minor effect on
aspiration flow; high vacuum is required to main-
tain occlusion.
c. Aspiration flow set too low.
Figure 8-17. LuxOr, the new Alcon microscope.
3. Inadequate aspiration:
a. There is a leak in the aspiration line.
b. There is air in the aspiration line.
c. The handpiece is clogged.
d. Flow rate and vacuum settings are too low and need
to be changed (Figures 8-16 and 8-17).
Zeiss’ Visalis 500
This is the new instrument marketed by Zeiss for sur-
gery of the anterior and posterior segment, presently avail-
able in 2 versions on the market, S and V. The first version
is dedicated to surgery of the anterior segment, whereas the
second can be used for surgery on both segments (anterior
and posterior). Both models have 2 pumps and changing
from one to the other is quick and simple—just touch the
control panel to switch from a peristaltic pump to a Venturi
pump. The pumps work with 1, single-use combined cas-
sette, tailored for both anterior and posterior segment sur-
gery. They have an incorporated reflux system and a mem-
brane pressure control system. The dual linear foot pedal
has multi-modulation phaco functions. The instrument
has a MICS22G coaxial technique platform, which allows
 Pumps of Newer Machines  113

surgeons to perform a small incision, keeping induced post-

operative astigmatism to a minimum. As fluid loss through
the tunnel is very limited, the control of intraocular pres-
sure is excellent. The stability of the anterior chamber is
also ensured by the surge security system (S3) sensor, which
monitors the vacuum level in the aspiration line.
The dual irrigation system has a gravity-operated mode
(with the bottle positioned up to 135 cm above the patient’s
head) and a controlled pressure mode, with a sterile BSS
collapsible bag and air fluid.
The instrument has various functions that clearly
express the reliability of Zeiss technology:
● Automated programmable modulation for the auto-
matic control of ultrasound power release according to
the surgeon’s preselected setting.
● Adaptive power control for the optimal release, in every
condition, of ultrasound power in the eye. There is con-
stant, real-time control of tip elongation and therefore
of stroke repetition, regardless of nucleus hardness. By
reducing energy, heat production is reduced.
● The integration of the CALLISTO (Carl Zeiss Meditec
AG) eye to display and record surgical procedures and
display system parameters in a frame in the micro-
scope eyepiece.
Visalis 500 V has dual illumination technology, that is, a
double light system with 2 distinct xenon lamps and the use Figure 8-18. New Visalis S500 phaco from Zeiss.
of 2 optic fibers at the same time (Figures 8-18 and 8-19).

Figure 8-19. Lumera 700 microscope from Zeiss.

114  Chapter 8
REFERENCES
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limit accuracy, and occlusion break surge of 3 new phacoemulsifi-
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2. Ratnarajan G, Packard R, Ward M. Combined occlusion-triggered
longitudinal and torsional phacoemulsification during coaxial
microincision cataract surgery: Effect on 30-degree miniflared tip
behavior. J Cataract Refract Surg. 2011;37:825-829.
3. Aust SD, Hebdon T, Humbert J, Dimalanta R. Hydroxyl free radi-
cal production during torsional phacoemulsification. J Cataract
Refract Surg. 2010;36:2146-2149.
4. Cionni RJ, Crandall AS, Felsted D. Length and frequency of intra-
operative occlusive events with new torsional phacoemulsifica-
tion software. J Cataract Refract Surg. 2011;37:1785-1790.
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under different vacuum levels in different degrees of nuclear cata-
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7. Han YK, Miller KM. Heat production: Longitudinal ver-
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Chang DF. Cataract Surgery Today. The best cataract and refractive
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Dillman DM, Maloney WF. Attualità in chirurgia della cataratta.
Facoemulsificazione. Verduci Editore; 1996.
Henderson BA. Essential of Cataract Surgery. Slack Incorporated; 2007.
Kelman CD. Phacoemulsification and Aspiration: The Kelman Technique
of Cataract Removal. Aesculapius Publishing Company; 1975.
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Strategies for the Spring, Crack and Stop & Chop Technique. 4th
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Seibel BS. Phacodynamics. Mastering the Tools and Techniques of
Phacoemulsification Surgery. 3rd ed. Thorofare, NJ: SLACK
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SOI—AICCER. Cataratta. Fabiano Editore; 1999.
RECENT ARTICLES
Aslan BS, Muftuoglu O, Gayretli D. Crater-and-split technique for
phacoemulsification: Modification of the crater-and-chop tech-
nique. J Cataract Refract Surg. 2012;38 (9):1526-1530.
Cavallini GM, Campi L, Torlai G, Forlini M, Fornasari E. Clear
corneal incisions in bimanual microincision cataract surgery:
Long-term Wound-healing architecture. J Cataract Refract Surg.
2012;38(10):1743-1748.
Christakis PG, Braga-Mele RM. Intraoperative performance and post-
operative outcome comparison of longitudinal, torsional, and
transversal phacoemulsification machines. J Cataract Refract
Surg. 2012;38(2):234-241.
Conrad-Hengerer I, Hengerer FH, Schultz T, Dick HB. Effect of femto-
second laser fragmentation of the nucleus with different softening
grid sizes on effective phaco time in cataract surgery. J Cataract
Refract Surg. 2012;38(11):1888-1901.
Deng JW, Yang YT, Zeng Y, Tang ZM, Liu XJ, Fu XY. Two-hook tech-
nique for nucleus extraction in manual sutureless extra capsular
cataract extraction. J Cataract Refract Surg. 2013;39(4):497-500.
Dick HB, Tim Schultz. Femtosecond laser-assisted cataract surgery in
infants. J Cataract Refract Surg. 2013;39(5):665-668.
Faramarzi A, Javadi MA, Karimian F, et al. Corneal endothelial cell
loss during phacoemulsification: Bevel-up versus bevel-down
phaco tip. J Cataract Refract Surg. 2011;37(11):1971-1976.
Friedman NJ, Palanker DV, Schuele G, et al. Femtosecond laser capsu-
lotomy. J Cataract Refract Surg. 2011;37(7):1189-1198.
Gonen T, Sever O, Horozoglu F, Yasar M, Keskinbora KH. Endothelial
cell loss: Biaxial small-incision torsional phacoemulsification
versus biaxial small-incision longitudinal phacoemulsification.
J Cataract Refract Surg. 2012;38(11):1918-1924.
Jardine GJ, Wong GC, Elsnab JR, Gale BK, Ambati BK. Endocapsular
carousel technique phacoemulsification. J Cataract Refract Surg.
2011;37(3):433-437.
Kerr NM, Abell RG, Vote BJ, Toh TY. Intraocular pressure during fem-
tosecond laser pretreatment of cataract. J Cataract Refract Surg.
2013;39(3):339-342.
Kim EC, Byun YS, Kim MS. Microincision versus small-incision coax-
ial cataract surgery using different power modes for hard nuclear
cataract. J Cataract Refract Surg. 2011;37(10):1799-1805.
Kim EK, Jo KJ, Joo CK. Comparison of tips in coaxial microinci-
sion cataract surgery with the bevel-down technique. J Cataract
Refract Surg. 2011;37(11):2028-2033.
Kurian M, Das S, Umarani B, Nagappa S, Shetty R, Shetty BK. Y sign:
Clinical indicator to stop trenching and start cracking. J Cataract
Refract Surg. 2013;39(4):493-496.
Lou B, Lin X, Luo L, Yang Y, Chen Y, Liu Y. Residual lens cor-
tex material: Potential risk factor for endophthalmitis after
phacoemulsification cataract surgery. J Cataract Refract Surg.
2013;39(2):250-257.
Malvazzi GC, Nery RG. Visco-fracture technique for soft lens cataract
removal. J Cataract Refract Surg. 2011; 37(1):11-12.
Mamalis N. Femtosecond laser: The future of cataract surgery?
J Cataract Refract Surg. 2011;37(7):1177-1178.
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pressure variation during femtosecond laser-assisted cataract
surgery using a fluid-filled interface. J Cataract Refract Surg. 2013;
39(1):22-27.
Talamo JH, Gooding P, Angeley D, et al. Optical patient interface
in femtosecond laser-assisted cataract surgery: Contact cor-
neal applanation versus liquid immersion. J Cataract Refract Surg.
2013;39(4):501-510.
Tognetto D, Cecchini P, Leon P, Nicola MD, Ravalico G. Stroke dynam-
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Refract Surg. 2012; 38(2):333-342.
Vasavada AR, Raj SM. Multilevel chop technique. J Cataract Refract
Surg. 2011;37(12):2092-2094.
Vasavada V, Vasavada AR, Vasavada VA, Srivastava S, Gajjar DU,
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dependent systems. J Cataract Refract Surg. 2013;39(4):563-571.
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tip construction. J Cataract Refract Surg. 2011;37(7):1329-1332.
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measurement of wound architecture in microincision cataract
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BIBLIOGRAPHY
Aust SD, Hebdon T, Humbert J, Dimalanta R. Hydroxyl free radical
production during torsional phacoemulsification. J Cataract
Refract Surg. 2010; 36:2146-2149.
Cionni RJ, Crandall AS, Felsted D. Length and frequency of intraop-
erative occlusive events with new torsional phacoemulsification
software. J Cataract Refract Surg. 2011;37:1785-1790.
Pumps of Newer Machines  115
Han YK, Miller KM. Comparison of vacuum rise time, vacuum limit
accuracy, and occlusion break surge of 3 new phacoemulsification
system. J Cataract Refract Surg. 2009;35:1424-1429.
Han YK, Miller KM. Heat production: Longitudinal versus torsional
phacoemulsification. J Cataract Refract Surg. 2009;35:1799-1805.
Ratnarajan G, Packard R, Ward M. Combined occlusion-triggered
longitudinal and torsional phacoemulsification during coaxial
microincision cataract surgery: Effect on 30°-degree mini-flared
tip behavior. J Cataract Refract Surg. 2011;37:825-829.
Rekas M, Montes-Mic R, Krix-Jachym K, Klus A, Stankiewicz A,
Ferrer-Blasco T. Comparison of torsional and longitudinal modes
using phacoemulsification parameters. J Cataract Refract Surg.
2009;35:1719-1724.
Wang Y, Xia Y, Zeng M, et al. Torsional ultrasound efficiency under
different vacuum levels in different degrees of nuclear cataract.
J Cataract Refract Surg. 2009;35:1941-1945.
All this is the past ... and present.
So, what does the future hold?
… Nothing is permanent except change … Buddha.
Section II

Femtosecond Laser Cataract Surgery
Stephen G. Slade, MD, FACS
We began our experience with femtosecond laser cata-
ract surgery in February 2010 and have been continually
impressed with the laser for use in cataract surgery. The
primary advantages are precision and reproducibility, both
of which provide direct benefits to the patient. By creating
a reproducible benchmark, femtosecond lasers also give
us the opportunity to learn more about the clinical sig-
nificance of such surgical steps as precisely sized and posi-
tioned incisions and capsulotomies. The image guidance
of these lasers is key; rather than simply create the incisions
and capsulorrhexis, we can now plan, position, monitor,
and measure these steps.
THE LEARNING CURVE
All new technologies come with a learning curve, and
the femtosecond laser is no exception. The procedure
does, however, draw heavily on lessons learned from other
ophthalmic surgeries, including laser-assisted intrastromal
keratomileusis (LASIK) and phacoemulsification. There
are two parts to the procedure—the laser portion and the
intraocular surgery. The laser portion involves planning the
surgery, entering the patient data and treatment plan, and
the laser treatment itself. Surgical planning is of utmost
importance, and although no manual skill is needed, the
lessons learned from examples of incorrect data entry in
LASIK are powerful teachers. Of course, drawing on the
experience of other users and a surgeon’s own early cases
can help with setting the laser parameters such as capsu-
lotomy diameter, incision construction, and the lens chop
and pattern. Docking is the main technical challenge with
the laser portion of the surgery. The patient interface is
- 119 -
9
different in design, and suction is applied longer at present;
however, the technique can easily be learned. Certainly, all
of the LASIK techniques used to achieve good exposure
and suction and recognize suction breaks and movement
become even more critical when intraocular surgery is
performed.
The intraocular portion of the surgery requires the sur-
geon to learn to recognize what the laser has performed in
each case and tailor the surgery accordingly, rather than
actually performing the incisions, chops, and so on. The
laser certainly makes the procedure easier, as the incisions,
capsulotomy, and lens chops are all completed. The surgical
key then is to verify the incisions, ensure that the capsulot-
omy is complete, and take advantage of the lens chops. For
example, the capsulotomy should be verified as complete
before the primary incision is opened and the chamber is
manipulated. Otherwise, capsular tags and incomplete cuts
could extend in untoward directions. No additional manual
skills are typically required, but the more cases a surgeon
performs, the better he or she becomes at determining how
to best manage each case. The laser shortens the intraocular
portion of the case, as fewer steps are required, but the total
time spent with the patient may increase with the addition
of the laser portion.
Does the laser allow a less skilled surgeon to perform
lens surgery or reduce the skills of an experienced surgeon?
I do not believe either of these to be the case. Good surgery
is the sum of one’s manual skills, practice, experience, and
judgment. The laser may reduce the number of manual
capsulotomies the surgeon performs; however, the less fre-
quently he or she performs capsulotomies, the less practice
he or she will have for difficult cases such as small pupils
or scarred corneas, so the skill level required is actually
increased. In reality, a surgeon will have to maintain or
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 119-127).
© 2014 SLACK Incorporated.
120  Chapter 9
Figure 9-1. Some cases may not be indicated for laser refrac-
tive cataract surgery. Because the laser cannot pass through
opaque media, in cases with small or misshapen pupils, such
as the heart-shaped pupil pictured, the laser will not be able to
make an effective capsulotomy or treat the lens. The laser can
still be used to make the corneal incisions, including astigmatic
cuts.
increase his or her skill level to compensate for the lack of
practice—certainly not allow his or her skills to decrease.
PATIENT SELECTION AND
INDICATIONS/CONTRAINDICATIONS
In my practice, the vast majority of our lens replace-
ment surgeries are primarily performed for patients with
cataracts. The presence of a cataract, therefore, is our major
case-selection criterion. We select patients whose daily
activities, based on our findings and their opinions, are
reduced or impaired due to cataracts. Although we strive
to provide the best possible refractive result and relative
freedom from glasses postoperatively, safety and ocular
health are our primary concerns and therefore drive our
patient selection.
There are additional criteria for patient selection that
are dictated by the laser, as not all patients are candidates
for laser cataract surgery. The suction ring requires reason-
able exposure and patient cooperation as well as a healthy
cornea and conjunctiva. The surgeon should remember
that docking the eye increases intraocular pressure (IOP),
as is the case with LASIK, yet, because the applanation lens
is curved, the increase in IOP will generally be lower than
it is with LASIK. However, patients with filtering blebs,
compromised optic nerves, and extensive corneal scarring
or previous surgery may not be good candidates for suction-
ring placement.
Because the laser cannot pass through the iris, patients
whose eyes dilate poorly or who have misshapen or
decentered pupils may not be the best candidates, either
(Figure 9-1). The laser likewise cannot pass through a white
cataract. In cases of white cataracts, we use the laser to
make the corneal incisions, including any astigmatic cuts,
and the capsulotomy, for which it does an excellent job. We
will often still use capsular dye in the eye to ensure that the
capsule is completely free before it is removed. Although
the laser cannot penetrate a white cataract, it is impressively
able to penetrate dark, hard nuclei, or “root beer” cataracts.
In our experience, if the surgeon is able to see some retinal
detail through the lens, even if highly colored, the laser can
typically cut the nucleus.
DAY OF SURGERY
We perform the procedure at our office-based ambu-
latory surgery center in Houston, Texas. Each patient is
examined and counseled in the clinic area one last time
just before surgery, which gives us the chance to speak with
him or her, perform a final slit-lamp examination to aid in
surgical planning, review the numbers of the laser param-
eters, and answer any remaining questions that the patient
or family members might have. The patient is then brought
into the surgery center and placed on a rolling, electronic
gurney (UFSK-International OSYS GmbH) in the preop-
erative area, which is next to the laser itself. He or she is
prepared in the usual fashion, in the gurney, with particular
attention paid to dilation.
When we are satisfied that maximal dilation is achieved,
we move the patient, again on the gurney, to the laser. The
data for the corneal incisions, any astigmatic cuts, and
the capsulotomy and lens cuts are reviewed and entered.
Next, the patient is placed under the laser, and the eye is
docked. The incisions, capsulotomy, and nucleus fragmen-
tation are then performed, and the patient is taken to the
operating room (OR) for the remainder of the procedure.
We try to minimize movement of the patient during the
entire process, especially between the laser and the OR, by
keeping the patient in the gurney. If there is an incomplete
capsulotomy, the capsulorrhexis is at risk during any move-
ment. We have also designed our surgical center so that the
preoperative area, the laser area, and the OR are as close
together as possible.
PREOPERATIVE MEDICATIONS
Preoperative medications used for laser cataract surgery
are quite similar to those used for standard lens surgery.
We sedate each patient, unless he or she declines, with oral
sedatives, including Valium (diazepam) or Versed (mid-
azolam). We also premedicate with antibiotics, steroids,
and nonsteroidal anti-inflammatory drugs. We do pay
more attention to the patient’s dilation. The application of

Figure 9-2. During the docking maneuver, as the patient interface
approaches the eye, an overlay of a real-time OCT is shown.
A B
Figure 9-3. An example of poor docking. (A) The eye is decentered in the suction ring, (B) which induces tilt of the lens and capsule,
limiting and adversely affecting the rest of the surgery.
the suction ring and the laser energy inside the eye tends
to bring the dilated pupil down. To counteract this, we use
Ocufen (flurbiprofen) preoperatively, as well as 10% phen-
ylephrine and 1% Mydriacyl (tropicamide) in every case.
I also use intraocular Shugarcaine on every case as a routine
(see Figure 9-5).
DOCKING AND LASER TREATMENT
Once the patient is ready for surgery, fully dilated, and
has provided informed consent, he or she is moved to the
laser. The patient remains in the powered gurney from the
preoperative area through the entire case—laser treatment,
OR, and recovery—which allows him or her to remain sta-
ble and prone so that any forces on the eye are minimized.
Femtosecond Laser Cataract Surgery  121
The key to docking is to avoid tilt and have a flat, planar
iris that is perpendicular to the laser beam (Figure 9-2). The
patient interface needs to be well centered on the limbus.
A tilted anterior segment, or decentered patient interface,
will limit the surgical options, affect the placement of the
primary incision at the limbus and the capsulotomy, and
may require the lens cuts to be repositioned (Figure 9-3). If
there is any question about placement or design of any of
the cuts, they can simply be left off of course and performed
manually. Often, the best option is to quit suction and repo-
sition the suction ring. The design of the skirt of the LenSx,
ring (Alcon, Novartis) makes repositioning easier than
with a metal-ring interface of a manual microkeratome.
The LenSx Laser also has a very useful fixation light that
helps with positioning. Each laser will have its own tips and
techniques to maximize docking, and the surgeon should
122  Chapter 9

A B

Figure 9-4. (A) A video image of the surgeon’s view is overlaid with “drag and drop” incisions and the capsulotomy parameters; top,
(B) an OCT section of the cornea in which a multiplane incision is planned and positioned; bottom, a section through the anterior
segment showing the lens for planning and placement of the nucleus cuts.

familiarize himself or herself with them and practice with

Figure 9-5. In this small pupil case, the diameter of the planned
capsulotomy was reduced, but the pupil continued to come
down and was contacted by the laser beam, which is also
possible with patient movement. In our experience, this is self-
limiting and does not affect the case.
the laser before his or her first cases.
The laser uses a real-time optical coherence tomography
(OCT) imaging system to map the eye and place the inci-
sions, capsulotomy, and nucleus cuts (Figure 9-4). During
the laser treatment, it is important for the surgeon to
carefully monitor the treatment as it progresses. Any poor
placements or execution of laser cuts will affect the intra-
ocular portion of the surgery. Decisions to modify or abort
certain steps may need to be made during the treatment.
We make it a point to hold the patient’s hand and talk to
him or her through the surgery. Of course, the status of the
suction ring also needs to be monitored so that any suction
break will be recognized (Figure 9-5).
After the laser treatment, we typically move the patient
immediately into the OR. We have not, however, found it
necessary to rush the patient to the OR. As long as he or
she remains relatively stationary, minutes or even hours can
pass between the laser treatment and relocation to the OR.

Figure 9-6. The eye as it presents in the OR. Corneal
incisions and the capsulotomy have been performed. In
this case, a cross-shaped nuclear chop pattern is evident,
as are gas bubbles behind the posterior aspect of the
nucleus and in front of the posterior cortex and capsule.
Figure 9-8. An incision that is too anterior will induce astigma-
tism and make the surgery more difficult.
THE INTRAOCULAR PORTION
OF LASER REFRACTIVE
CATARACT SURGERY
The key difference in the intraocular portion of laser cat-
aract surgery is that the surgeon has to assess and recognize
the steps that the laser has or has not completed before he or
she begins the manual portion. In most instances, the laser
has performed approximately half of the case (Figure 9-6).
For example, rather than performing the primary incision,
the surgeon evaluates the laser incision and determines
whether or not its placement is correct, if it is complete and
patent, and if any modifications are required (Figure 9-7).
Femtosecond Laser Cataract Surgery  123
Figure 9-7. Although the lens chop has been completed, it is
the surgeon’s responsibility to notice the small bridge in the
capsulotomy at 2 o’clock.
INCISIONS
Typically, there is no need to re-cut the main or side-
port incisions. The entry sequence into the eye, however, is
different in laser cataract surgery. It is important that the
chamber is stabilized and there is no sudden loss of ante-
rior chamber pressure. I simply verify that the incisions are
open using a blunt instrument (Slade laser spatula, ASICO).
First, I go in through the sideport, put in the Shugarcaine,
followed by the viscoelastic agent (Duovisc). When the
anterior chamber has been stabilized, I open the primary
incision with the same laser spatula. We currently use a
three-planed trapezoidal incision, designed with a 2.2-mm
internal opening, a 2.4-mm external width, and a tunnel
length of 2.0 mm. The control, reproducibility, and preci-
sion of a laser incision are evident. We are also able to
directly compare the efficacy of a series of incisions with
one set of parameters, then change only one, and with the
consistency of the laser, discover which parameters are best.
It is important that the main incision is placed at the
limbus. We plan to place the incisions just within the ves-
sels of the limbus. If the incision is too anterior, it will
induce astigmatism and make the case more difficult to
perform from an awkward angle (Figure 9-8). If the incision
is too posterior, and on the sclera, it will not be patent, as
the laser will not cut through opaque media and will need
to be opened with a traditional blade.
THE CAPSULOTOMY
As in manual surgery, the capsulotomy is key to the
success of the rest of the surgery (Figure 9-9). The sur-
geon should carefully inspect the capsulotomy for centra-
tion, completeness, and circularity, looking particularly for
124  Chapter 9

Figure 9-9. A complete, round, well-centered laser capsulotomy.

any tags. The surgeon should also be careful to ensure that

the capsule is complete and without bridges or tags before
removal to avoid any extension of an incomplete rhexis.
I use a cystotome or forceps to confirm that the capsu-
lotomy is free. I then use gentle hydrodissection under the
edge of the capsule to detach the nucleus.
Although a laser capsulotomy may be as strong as or
stronger than a standard manual capsulotomy, there are
no guarantees against a radial tear or extension, so a gentle
hydrodissection should be performed. There is also a pos-
sible increase in the chance of a capsular block syndrome,
as there is more mass behind the lens in the form of gas,
to push the lens forward. The anterior capsule is typically
perfectly round and centered, therefore acting as a perfect
seal when the nucleus rises up from irrigation fluid placed
posteriorly. Again, smaller bore cannulae and a carefully
monitored technique are important.
The size of the capsulotomy appears to affect the amount
of lens tilt, such that a smaller diameter may result in less
tilt in some lenses. The laser gives us the ability to custom-
ize the diameter, and in the future, possibly the centration,
of the capsulotomy to each individual lens and patient.
Figure 9-10. Hydrodissection with a large-gauge cannula and
an iris block to the incision. This may allow a rapid, dramatic
rise in pressure in the anterior chamber and posterior capsular
rupture.
can rise immediately and dramatically to the point of forc-
ing a rupture in the posterior capsule. Interestingly, laser
refractive cataract surgery may be more prone to this com-
plication. In laser refractive cataract surgery, there is gener-
ally already pressure in the form of gas bubbles from the
laser treatment behind the nucleus. As detailed previously,
the perfectly round, centered laser capsulotomy may form
a better, quicker, and stronger seal to allow the pressure to
rise. It is therefore important to gently hydrodissect in these
cases while making sure that fluid is escaping from behind
the nucleus and out of the eye. As shown in Figure 9-10, if
the iris is allowed to block the incision, then the pressure
may rise to the point of capsular rupture.

VITREOUS LOSS PHACOEMULSIFICATION

The risk of a broken capsule leading to vitreous loss is OF THE NUCLEUS
a serious complication in cataract surgery. Although the
incidence seems to be less than in manual cataract surgery,
Surgeons often ask how the femtosecond laser will affect
cases of vitreous loss have occurred in laser cataract surgery.
phacoemulsification. I think it is the perfect partner for
We have carefully examined three cases that were presented
phacoemulsification because it will allow us to optimize
to us, and in all three, we found causes other than the laser.
our phaco machines and techniques. We have used a variety
Our findings have agreed with the surgeons’ impressions.
of techniques to remove the fragmented nucleus—divide
For example, in two cases where there was a posterior cap-
and conquer, vertical chop, horizontal chop—and the laser
sule rupture during hydrodissection, careful viewing of the
works well with them all (Figures 9-11 and 9-12). Currently,
surgical video revealed the likely development of anterior
we are concentrating on optimizing our cataract surger-
capsular block syndrome. Anterior capsule block has been
ies using the INFINITI Vision System, Ozil IP torsional
reported in the literature with manual cataract surgery. In
ultrasound (Alcon Laboratories, Inc), with different tips
anterior capsular block, a forceful hydrodissection pushes
and settings. I am impressed with this system’s capacity
the nucleus up against the anterior capsular rim. If a seal
for adjusting amplitude and flow rates in response to the
at the rim is affected, then the pressure behind the nucleus

Figure 9-11. An in-depth view of a cross-chop pattern in
the lens. A layer of bubbles extends down through the depth of
the nucleus, and gas bubbles are seen anteriorly and beneath
the posterior level of the nucleus.
varieties of nuclei. We are exploring how to adapt these
technologies for combined use. For example, for soft nuclei,
we can use a series of soft cylinders to liquefy the cataract,
pick a specific phaco handpiece tip, and then perform irri-
gation/aspiration. We use the blend of femtosecond laser
and phacoemulsification to improve our speed, safety, and
outcomes.
CURRENT NUCLEAR REMOVAL
TECHNIQUE: CYLINDER CHOP
The current technique that we use, cylinder chop, is
based on the latest software for the LenSx Laser. This soft-
ware reduces the time for the laser portion of the surgery
with intelligent ways to improve the efficacy of the capsu-
lotomy, chop, and incisions and enables the cylinder chop
technique. We have obtained our best results to date with
this technique. In addition, it provides the most reproduc-
ible nucleus disassembly that we have seen with any tech-
nique, laser, or nonlaser. The technique provides outstand-
ing, consistent control over a wide range of nuclei.
The cylinder chop technique begins with a set of nested
cylinders created in the center of the nucleus (Figure 9-13).
The outer diameter of the largest cylinder is 3.5 mm but
may be set to the surgeon’s preference. A simple cross pat-
tern is also programmed and can be seen (see Figure 9-13),
with its outer diameter currently set at 5.5 mm. The nucleus
pattern is brought up to just below the anterior capsule and
set a bit higher off the posterior capsule than in the past.
This allows the gas bubbles to escape anteriorly and have
less of an effect in pressurizing the nucleus as previously
mentioned.
Femtosecond Laser Cataract Surgery  125
Figure 9-12. In this view, a cross-section of the nucleus is shown.
The chop pattern of opaque bubbles is seen to extend down to
approximately the level of the posterior cortex.
Once the laser treatment is completed and the patient is
moved into the OR, the intraocular portion of the surgery
proceeds differently as well. The first step is to check the
completeness of the capsulotomy (Figure 9-14). Again, this
should be done with as little change in the anterior chamber
pressure as possible.
Once the capsule is verified and removed, the nucleus
disassembly begins. We begin by using the Ozil Tip (Alcon
Laboratories, Inc) to core out the center portion that has
been lasered with nested cylinders. In our experience, this
central core comes out easily with a pre-phaco setting on
the phacoemulsification unit with Ozil energy only and
low suction. Often, the quadrants defined by the cross-chop
pattern will begin to come apart even this early in the pro-
cedure (Figure 9-15).
Once the central core is removed, the phaco tip and a
second instrument are used in a “crossed swords” technique
to complete the separation of the quadrants of the nucleus,
if this has not been accomplished spontaneously in the pre-
vious step (Figure 9-16).
Once the quadrants are separated, the first section
is brought out with the “chop” high-vacuum setting on
the phacoemulsification unit. This higher-vacuum, lower-
power setting, combined with a quadrant that has its apex
removed for increased space, allows the first quadrant to
be easily and consistently brought up into the anterior
chamber to be emulsified. The setting is then changed to
“quadrant removal” for the emulsification of the quad-
rants and completion of the nucleus removal. “Quadrant
removal” is a lower vacuum but higher-power setting
designed to rapidly remove nuclear material. The remain-
der of the case, cortex removal and lens insertion, are
carried out in a standard fashion.
The cylinder chop technique takes advantage of the
laser’s ability to work with phacoemulsification. We have
adjusted and customized the settings of the 2 devices to
complement each other in this technique for the first time.
As the technologies develop, and we gain more experience,
I believe we can look forward to increased synergy between
126  Chapter 9

A B

Figure 9-13. (A) Laser settings in the cylinder chop technique. Note the set of nested cylinders and the radial chop being completed
on the video camera view. The capsulotomy has been performed, evidenced by the ring of gas bubbles. (B) The setting of the cap-
sule cutting (upper right) and the depth and placement of the lens chop (lower right) can be seen on the OCT image.

Figure 9-14. The capsule is checked to ensure that there are no Figure 9-15. The angled Ozil tip with a Kelman angle is used to
tags or bridges. core out the center portion of the nucleus to 80% depth. Gaps
between the quadrants are evident, even at this early stage of
the nucleus disassembly.

the laser and phaco machine in ways that we can only

imagine.

Figure 9-16. The phaco tip and the second instrument may now
be used to completely break apart the quadrants of the nucleus.
CORTEX
The epinucleus is typically disengaged from the cortex
from the LenSx Laser’s gas hydrodissection and is easy
to aspirate and emulsify. Likewise, the cortex has a well-
defined edge and aspirates well, often in one piece. In some
cases, however, the cortex may take longer to remove than
the surgeon is accustomed to. There may be a smooth cut

edge right at the capsulotomy rather than the more easily
engaged tags in manual cataract surgery. In some cases, the
gas pressure beneath the lens may push the cortex against
the capsule, making the aspiration more challenging. In
these cases, it often helps to try to hydrodissect the cortex
more extensively from the capsule at the start, or after the
nucleus is out, come back, and run fluid or viscoelastic
agent under it.
TECHNIQUE AND SAFETY
ADVANTAGES IN DIFFICULT CASES
Femtosecond lasers may also be advantageous in diffi-
cult cases, such as those of compromised zonules, traumatic
cataracts, and pseudoexfoliation. In these cases, there may
be added safety in a “no-touch” capsulorrhexis. By using
the laser, we do not have to stress the zonules when mak-
ing the capsulorrhexis or chopping the nucleus, which
could yield fewer dislocated lenses and dropped nuclei.
The laser also helps with white cataracts, dislocated lenses,
and fibrous capsules. We are better able to optimize the
dimensions and construction of the cataract incision and
perform it repeatedly with the laser. This may lead to fewer
wound leaks, improved lens stability, and lower infection
rates. Better wounds could also lower induced astigmatism,
resulting in fewer required secondary procedures and their
associated risks.
SUMMARY
The femtosecond laser provides tremendous benefit to
both the patient and the surgeon. The added precision of
the arcuate cuts enables my postoperative patients to see
well, and the laser can perform these cuts better than I can.
The laser also adds precision to the capsulotomy, which,
in most patients, can also perform better than I can. It
is a superb refractive machine, which makes no mistake,
and the surgery must be completed by the surgeon. Does
this diminish the role of the ophthalmic surgeon? Having
used the laser since early 2010, I can report the answer is
no. In fact, this surgery requires me to be a better surgeon
than I was before. In the past, I had a lot of practice with
capsulotomies and cracking different types of nuclei. Now,
the capsules I manage are the difficult ones, or small pupils
or incomplete rhexii, and the nuclei that I must crack
Femtosecond Laser Cataract Surgery  127
completely are also small pupils, super hard, white, and so
on. I have had to learn to recognize what the laser has or has
not done, and I have become a better observer and student
of the surgery. Overall, the laser improves my refractive
results and has truly enabled me to become a better cataract
surgeon.
SUGGESTED READINGS
Aykan U, Bilge AH, Karadayi K. The effect of capsulorrhexis size
on development of posterior capsule opacification: small (4.5
to 5.0 mm) versus large (6.0 to 7.0 mm). Eur J Ophthalmol.
2003;13:541-545.
Cekiç O, Batman C. The relationship between capsulorrhexis size
and anterior chamber depth relation. Ophthalmic Surg Lasers.
1999;30(3):185-190.
Holladay JT. IOL power calculations for multifocal lenses. Cataract
Refract Surg Today. 2007;3:71-73.
Holladay JT, Prager TC, Chandler TY. A three-part system for refin-
ing intraocular lens power calculations. J Cataract Refract Surg.
1988;13:17-24.
Holladay JT, Prager TC, Ruiz RS, Lewis JW. Improving the pre-
dictability of intraocular lens calculations. Arch Ophthalmol.
1986;104:539-541.
Hollick EJ, Spalton DJ, Meacock WR. The effect of capsulorrhexis size
on posterior capsular opacification: one-year results of a random-
ized prospective trial. Am J Ophthalmol. 1999;128:271-279.
Kezirian GM. Qualifying visual performance with the Crystalens.
Cataract Refract Surg Today. 2010(Suppl):3-4.
Nagy Z. Intraocular femtosecond laser applications in cataract surgery:
precise laser incisions may enable surgeons to deliver more repro-
ducible outcomes. Cataract Refract Surg Today. 2009;9(9):29-30.
Nagy Z. Use of femtosecond laser system in cataract surgery. Paper pre-
sented at the XXVII Congress of the ESCRS; September 15, 2009;
Barcelona, Spain.
Nagy Z. Use of the femtosecond laser in cataract surgery. Paper
presented at the AAO annual meeting; October 27, 2009; San
Francisco, CA.
Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of
an intraocular femtosecond laser in cataract surgery. J Refract
Surg. 2009;25(12):1053-1060.
Norrby S. Sources of error in intraocular lens power calculation.
J Cataract Refract Surg. 2008;34(3):368-76.
Poll JT, Wang L, Koch DD, Weikert MP. Correction of astigmatism dur-
ing cataract surgery: toric intraocular lens compared to periph-
eral corneal relaxing incisions. J Refract Surg. 2011;27(3):165-171.
Slade SG, Culbertson WW, Kreuger RR. Femtosecond lasers for
refractive cataract surgery. Cataract Refract Surg Today.
2010;10(8):67-69.
Szigeti A, Kranitz K, Takacs A, et al. Comparison of long-term visual
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Surg. 2012;28(9):609-614.

Femtosecond Laser-Assisted
Cataract Surgery
Pavel Stodulka, PhD
INTRODUCTION AND HISTORY
The contemporary cataract surgery has the following
features: outpatient procedure, topical anesthesia, micro-
incision, short surgical time, sutureless. Surprisingly, if
we apply these features to ancient reclination, they all fit
exactly. Of course, the modern cataract surgery is much
safer and injectable intraocular lenses (IOLs) make the out-
come totally different from reclination.
There were several attempts to employ lasers for cata-
ract surgery in the past. During the last decade of the
20th century, a German company Aesculap Meditec
introduced an Er:YAG laser for cataract surgery and an
American company Paradigm Medical Industries came
with a Photon laser system with a mechanical microspoon
on which a laser was firing to dissipate lens material. The
most popular historical laser cataract system was Lyla from
a German company ARC laser. A few devices are still in
clinical use. A YAG laser-generated pulse hits a titanium
target at the end of the disposable laser probe (Figure 10-1)
and generates a shock wave intended to disrupt the lens
material. The Dodick laser was the first device suitable for
a microincision cataract surgery at the beginning of the
21st century. Further developments lead to a modification
used for cleaning the inner surface of the lens capsule to
prevent posterior capsular opacification. But it was not
until the femtosecond lasers appeared that lasers took over
in a field of cataract surgery. Femtosecond laser application
is the latest development step in cataract surgery. The first
- 129 -
10
surgeon to attempt to perform femtosecond laser-assisted
cataract surgery on human eyes was Z. Nagy in Hungary.1
The laser has an ambition to make the surgery more precise,
more reproducible, safer, and to further decrease the ultra-
sound energy needed for lens emulsification. For the first
time ever, certain steps of the cataract surgery are being
performed automated and independent from the surgeon’s
hand. It is possible because of the precise optical coher-
ent tomography (OCT) identification of ocular structures
and precise delivery of laser energy coupling the direction
of the laser beam with the OCT image. All of this is pos-
sible thanks to the modern computers driving the device.
Femtosecond lasers perform corneal incisions including the
corneal relaxing incisions, lens capsulotomy, and lens frag-
mentation. All this is done after docking the patient under
the laser device. This is an extra step in cataract surgery,
making the logistics of operation more complex. There is
currently a controversy whether the laser is going to make
the efficacy of surgery lower or higher. At the time of writ-
ing this text, there were little data confirming the outcome
of laser surgery is superior to ultrasound surgery. There are
initial data available that precise and well-centered round
capsulotomy will provide more predictable postoperative
effective lens position,2–5 less internal aberrations,6 and
perhaps less posterior capsular opacification (PCO). Short
time of manual intraocular surgery with less ultrasound
energy 7 should also result in lower endothelial cell loss.8 It
is very probable that femtosecond lasers are going to revolu-
tionize cataract surgery and change the surgical paradigm
even though the outcomes will very likely not be that much
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 129-137).
© 2014 SLACK Incorporated.
130  Chapter 10
Figure 10-1. Intraocular disposable laser probe for cataract
surgery from ARC laser.
improved as it was by ultrasound phacoemulsification over
the intracapsular lens extraction.
PRINCIPLES OF FEMTOSECOND
LASER EYE SURGERY
The mechanism of the femtosecond laser pulse interac-
tion with tissue is called laser-induced optical breakdown.
A cut is made by placing thousands of laser pulses next to
each other in a computer-generating pattern. This process
enables cutting inside of the closed eye or inside the eye
wall.
Very short pulses of the femtosecond laser focused into
tissue cause an optical breakdown at the beam focus. High
energy concentration within a short time generates micro-
plasma followed by cavitation bubble creation and shock-
wave. The microplasma bubble is only 1 to 5 μm small and
is composed of carbon dioxide and water vapor. It expands
several times larger to become a cavitation bubble of size
determined by the laser energy. Each bubble coalesces or
they are very close together. Tissue cutting is a nonthermal
effect with no thermal damage to the adjacent tissue.
During laser-assisted cataract surgery, complex 3-dimen-
sional (3D) computer-generated patterns of laser spots cre-
ate cuts inside of the lens or cornea. The studies about the
safety of intraocular femtosecond laser pulses had to be
done mainly concerning the safety of endothelium and
retina8–10 before the clinical application.
Femtosecond Lasers Available
for Cataract Surgery
There are 4 femtosecond lasers for cataract surgery avail-
able on the market:
1. LenSx (Alcon Laboratories, Inc)
2. LensAR (LensAR)
3. Victus (Technolas Bausch + Lomb)
4. Catalys (OptiMedica/Abbott)
LenSx is the first femtosecond laser for cataract surgery
on the market (Figure 10-2). The laser was first evaluated in
clinical practice by Z. Nagy in Budapest, Hungary. LenSx
platform features an OCT image displaying the ocular
structures via a curved interface, but the new “soft-tip”
patient interface has essentially eliminated corneal wrin-
kling and significantly improved the capsulorrhexis.
LensAR features a Scheimpflug imaging system and
uses ray tracing for 3D reconstruction of anterior eye seg-
ment (Figure 10-3). The device is mobile on wheels (eg, in
between operating rooms).
Victus today is the only device that displays ocular
structures during the entire procedure by online OCT
(Figure 10-4). It uses a curved interface with a set of pres-
sure sensors monitoring not only vertical but also the side
forces during docking, planning, and laser procedure to
minimize corneal folds. The only platform suitable also for
LASIK flap creation and Intracor refractive surgery.
Catalys laser has a patented liquid optic interface in
between the laser and patient eye (Figure 10-5). The trans-
parent liquid fills the space above the cornea and laser
cone and minimizes corneal folds during docking of the
patient. The ocular structures are visualized by a propri-
etary Fourier-domain OCT. The lens fragmentation process
is capable of fragmenting lens material into small cubes.
There will soon be more lasers from manufactures available
for cataract application (eg, Ziemer).
Laser-Assisted Cataract Surgery Steps
The laser-assisted cataract surgery consists of the follow-
ing surgical steps:
1. Femtosecond laser part
a. Docking
b. Planning
c. Capsulotomy
d. Lens fragmentation
e. Main incision
f. Side port incisions
g. Corneal relaxing incisions
2. Manual part
a. Incision opening
b. OVD injection
c. Central anterior capsule removal
d. Hydrodissection
e. Phacoemulsification
f. Cortex aspiration

Figure 10-2. Femtosecond laser LenSx. (Reprinted with permis-
sion from Alcon Laboratories, Inc.)
Figure 10-4. Femtosecond laser Victus (TECHNOLAS PV, Bausch
& Lomb).
g. Posterior capsule polishing
h. IOL implantation
i. Viscoelastic removal
j. Wound closure
Femtosecond Laser Part
Docking: Femtosecond lasers are supposed to create 3D
patterns into ocular structures—cornea and lens—during
cataract surgery. Currently, all lasers need a steady connec-
tion between the laser and the eye through an interface to
reach the target with the desired precision. All lasers use a
disposable interface attached to the operated eye by suction.
The interface acts as the connection between the patient
eye and the laser system. The procedure connecting the
eye with the device is called docking. Typically, a patient
is lying on an electrically driven bed under the laser and
either the bed is manipulated via joystick to bring the oper-
ated eye in contact with the laser interface or the cone of
Femtosecond Laser-Assisted Cataract Surgery  131
Figure 10-3. Femtosecond laser LensAR (LENSAR, Inc).
Figure 10-5. Femtosecond laser Catalys (OptiMedica/Abbott
Laboratories).
the laser system is moved toward the patient. As the forces
to manipulate the bed with the patient are quite high, it
has to be ensured that the eye is by no chance exposed to
overpressure. Therefore, the laser cones are equipped with
a vertical pressure sensor. Only the cone of Victus laser is
equipped also with a set of lateral pressure sensors to direct
the docking pressure force evenly toward the center of the
cornea. Laser cones are typically curved to fit the curvature
of a human cornea and to minimize corneal folds during
docking as the folds interfere with the planned laser focus
delivery. The Catalys and the LensAR systems feature a liq-
uid interface where transparent liquid in between the laser
cone and cornea transmits the laser beam onto the eye and
prevents corneal distortion.
132  Chapter 10
Planning: The planning is started before the docking
procedure by entering or importing the patient identifi-
cation data and data from diagnostic instruments. The
surgeon can decide about capsulotomy, lens fragmenta-
tion, and corneal incisions. It is possible to choose from a
pre-stored pattern or select individually all data for each
surgical step. Spot energy, vertical, and horizontal spot
separation can be selected for each surgical step. Regarding
the capsulotomy, a diameter, centration, height of laser spot
ring under and above capsule, tilt of this ring pattern can
be defined. Capsulotomy is being performed as the first
step mostly to allow gas bubbles to escape from the capsu-
lar bag. The gas bubbles created during lens fragmentation
performed before capsulotomy could create tension inside
of the capsular bag high enough to rupture the capsule.
For lens fragmentation, a particular pattern is chosen. The
last step is usually the creation of corneal incisions. Most
of the devices allow for both main and side port incisions
and corneal relaxing incisions. After docking the eye under
the laser aperture, OCT or Scheimpflug imaging is going to
display ocular structures. Manual marking of ocular struc-
tures is mostly required. When all required data are entered
and confirmed, the laser is ready to start the procedure.
Capsulotomy: Circular anterior capsule lens opening
performed by laser is no longer called capsulorrhexis but
laser capsulotomy as it is not created by tearing the cap-
sule but by firing the laser spots into the capsule and its
surroundings. The femtosecond laser places laser spots in
cylindrical shape starting posterior to the capsule inside
the lens and going in a spiral pattern anterior to the capsule
to ensure cutting the capsule 360 degrees around in desired
diameter. The maximum laser capsulotomy diameter is
determined by laser technical parameters or by pupil diam-
eter, as it is not possible to shoot the laser to the capsule
under the iris currently. Capsulotomy is usually created
in a circular pattern. Laser capsulotomies are very evenly
circular. It was proven that the strength of the laser cap-
sulotomy outperforms the manual one.11 It is also possible
to perform elliptical capsulotomies or theoretically capsu-
lotomies of more complex shapes. The central capsule is
either free floating in the anterior chamber or so-called free
laying at its original place with no bridges to the peripheral
capsule. It is possible to aspirate the free central capsule by
a phacoemulsification tip. Sometimes, the central capsule
can still be connected by tissue bridges to the peripheral
capsule. There are 2 possible ways to handle this situation
preventing a creation of radial anterior capsule tear with the
risk to spread to the lens equator and further to posterior
capsule. The first possibility is to grasp the capsule by a cap-
sulorrhexis needle and peel it off in circular or centripetal
direction. The second possibility, which is preferred by the
author of this chapter, is to grasp the central capsule with
aspiration by a phaco tip and pull it anteriorly creating a
centripetal force. With a small circular movement of phaco
tip while aspirating and pulling anteriorly, it is possible to
safely remove the central capsule from the peripheral ante-
rior capsule. The author do not stain the capsule with try-
pan blue to enhance its visualization routinely. In a small
fraction of eyes, it is possible to see small irregularities or
sometimes larger tags (Figure 10-6) at the capsulotomy
boarder. Capsules do not show a significant tendency to
tear at such irregularities or tags, which one would expect
with a manual capsulorrhexis.
Lens Fragmentation: The purpose is to fragment the lens
material into smaller pieces by laser spots. Different pat-
terns are used clinically.12 In general, the laser starts to aim
pulses posterior in the lens and moves anterior. The safety
distance from the posterior capsule is dependent on the
laser system and is normally approximately 500 μm. The
lateral fragmentation is limited to a capsulotomy diameter
with some users, but the lens can be fragmented lateral to
the capsulotomy diameter (Figure 10-7). Some platforms
limit the lateral diameter of the fragmentation pattern by a
pupil diameter. Most platforms use a combination of cylin-
drical and radial fragmentation patterns. The Catalys plat-
form fragments lens material into small cubes. It might be
more effective to fragment the lens material into hexagons
to better fit the pieces into the tip of the phacoemulsifica-
tion handpiece. The energy of laser per spot is in range of
micro-Joules. Both horizontal and vertical spacing of laser
spots can be adjusted to obtain optimal tissue separation.
Basically, the fragmentation facilitates lens crack and emul-
sification with the reduction of both lens emulsification
time and ultrasound energy. Generally the laser lens frag-
mentation is performed after the laser capsulotomy, which
enables the gas bubbles generated by laser fragmentation
to escape from the capsular bag. Different fragmentation
patterns are designed to best fit different lens hardness and
also the surgeon’s preferences.
Main Incision: The laser incisions have a potential for
very precise 3D shape with excellent sealing properties.
The main incision can be performed at any axis. Usually,
it is performed at 12 o’clock position or at the steepest cor-
neal meridian or at a meridian convenient for the surgeon.
The placement, including the distance from the center and
limbus, is typed in the device. The peripheral wound edge
should be central to the limbus as the laser spots decrease
their tissue separation potential within the vascularized tis-
sue. The length, width, and shape of the main incision can
also be programmed. The incisions are not self-opening,
so the procedure can be performed at a laser room outside
of the operating room. Patients can walk to the operating
room after the laser procedure. In the operating room, the
incision can be opened by a spatula separating the tissue
bridges. The laser incision with its 3D shape has the poten-
tial for excellent sealing even without hydration.
Side Port Incisions: Side port incisions are usually per-
formed 120 or 90 degrees apart. Again the side port inci-
sion, like the main one, can have preprogrammed different

Figure 10-6. Detail of laser capsulotomy with a capsular tag.
length, width, and shape and they have to be opened by a
surgical instrument.
Corneal Relaxing Incisions: Corneal relaxing incisions
are cuts performed in the periphery of the cornea to com-
pensate for regular corneal astigmatism. The shape of the
cuts is a partial ring with a diameter of usually 8 to 11 mm.
In most cases, these so-called arcuate incisions consist of a
pair of 2 cuts with a depth of about 80% to 90% of corneal
thickness. The diameter, depth, and open angle of the arcu-
ate incisions are related to the amount of cylinder to be
corrected. It has been proven on manual corneal relaxing
incisions that they can correct astigmatism with a long-
term stable result. The laser corneal relaxing incisions have
a potential for higher precision in position, length, width,
and shape. Therefore, one can anticipate that also the
outcome can be more consistent compared to the manual
corneal relaxing incisions. There are different nomograms
used for laser corneal relaxing incisions. Theoretically, it
is possible to perform laser arcuate relaxing incisions only
intrastromally under the Bowman membrane to minimize
pain and risk of epithelial invasion into the incision. Such
an approach will need a clinical evaluation and develop-
ment of adequate nomograms.
Manual Part
Incision Opening: After the laser part of the surgery,
the patient is either swung on the bed under the operating
microscope in the same operating room to complete the
surgery or the patient sits up and walks into the separate
operating room for the intraocular part of the surgery. The
laser incisions are not opening spontaneously. One needs
a spatula to open the laser incisions after the patient was
draped and the speculum placed.
OVD Injection: It is recommended to use only very
limited amount of ophthalmic viscosurgical device (OVD)
to maintain anterior chamber. The OVD can also push
the central capsule away from its position. It can be either
folded into about halves or pushed anteriorly into ante-
rior chamber. The author recommend to simply injecting a
small amount of OVD into anterior chamber and leave the
Femtosecond Laser-Assisted Cataract Surgery  133
Figure 10-7. Eye after the laser capsulotomy and lens frag-
mentation with a pattern reaching outside of the capsulotomy
diameter and restricted by the pupil diameter.
central capsule in its original position. The author call this
position a “free lying capsule.”
Central Anterior Capsule Removal: The next step is to
remove the central portion of anterior lens capsule. There
are 2 possible ways to remove it. Classically, it is recom-
mended to use a capsulorrhexis forceps to grasp the central
capsule and gently peel it off in a circular and centripetal
direction. The author recommend not to use the forceps
but to aspirate the capsule onto a tip of phacoemulsifica-
tion handpiece. In case of a free-floating capsule, it is just
aspirated by a phaco tip (Figure 10-8) sometimes using a
single pulse or a burst of ultrasound. While the capsule is
being held by a phaco tip, the author pulls it anteriorly and
perform a small circular movement with the phaco tip. By
this maneuver, the capsule can be safely detached from the
capsular bag even in the case of small tissue bridges, which
might connect the central capsule with the capsular bag.
When the capsule is lifted, it is easy to aspirate it with high-
er vacuum and perhaps a small pulse or burst of ultrasound.
Hydrodissection: This step is significantly different from
conventional ultrasound cataract surgery. The difference
is caused by gas bubbles present in the lens after laser
lens fragmentation. The tension caused by the gas might,
together with the tension of solution injected during
hydrodissection, rupture the capsular bag. To avoid this
complication, the author recommend first performing a few
strikes by a phaco tip into the lens material. Pushing on the
lens material posteriorly by a phaco tip often enables a few
bubbles to escape from the capsular bag to release the pos-
sible tension inside of the bag. Then while holding the lens
by an aspirating phaco tip and lifting it slightly anterior,
the author inject a limited amount of solution under the
anterior capsule in the direction of the lens equator to per-
form hydrodissection. The pressure of gas bubbles, injected
solution during hydrodissection, and lifting force of phaco
tip all together help to push the lens material anteriorly and
detach it from the posterior capsule.
134  Chapter 10
Figure 10-8. Free-floating capsule being aspirated by a phaco
tip.
Phacoemulsification: After cleaning the anterior cortex
overlaying the nucleus, the author dipped the phaco tip
inside of the nucleus and lifted up a central nuclear cyl-
inder with a high aspiration of up to 600 mm Hg (Figure
10-9). The next step is aspiration and emulsification of the
nucleus facilitated by ultrasound if needed. The quadrants
pre-fragmented by laser are then emulsified. The author
recommend pulling the lens material by a phaco tip toward
the center of the pupil for safe and effective phaco aspira-
tion with minimal use of ultrasound provided the lens is
not +4 hard.
Cortex Aspiration: After the nucleus and epinucleus have
been aspirated, it is still possible to continue with cortex
removal by a phaco tip as it goes faster through a wider
opening of the phaco tip compared to a bimanual cannula.
Usually, bimanual cannulas through side port incisions are
used for cortex removal. The aspiration can be set as high
as 600 mm Hg. The author do not find the aspiration of lens
cortex material any different in laser-assisted cataract sur-
gery compared to ultrasound phacoemulsification surgery.
Some surgeons feel that it is more difficult to aspirate the
lens cortex after laser lens fragmentation because the laser
cuts through the anterior cortex during capsulotomy.
Posterior Capsule Polishing: The posterior lens capsule
polishing is the next surgical step. The low vacuum aspira-
tion sometimes with a diamond dust-covered instrument
and solution stream are used.
IOL Implantation: After the capsular bag has been
appropriately cleaned, the IOL is injected. The author
recommends injecting the lens without filling the bag and
anterior chamber with OVD. The eye is pressurized by an
irrigating biaxial cannula inserted through one of the side
incisions. Therefore, there is usually very little or no OVD
to be aspirated from anterior chamber or capsular bag after
IOL implantation and there are virtually no postoperative
pressure spikes.
Viscoelastic Removal: Providing the IOL was injected as
described previously, there is usually no need to perform
OVD aspiration, which can be performed by irrigation and
aspiration via bimanual cannulas.
Figure 10-9. The central nuclear cylinder lifted up by a phaco
tip.
Wound Closure: The laser 3D incisions have a self-
sealing tendency, providing they were not traumatized by
surgical instruments during the manual part of the surgery
and usually do not require hydration. It is possible to seal
them by pressure hydration by a cannula on a syringe. The
eye is usually pressurized by a solution injected via a side
port incision at the end of intraocular surgery. It is advised
to inject intracameral antibiotics to prevent endophthalmi-
tis. It is also possible to inject antibiotics into the corneal
stroma during wound hydration. In very exceptional cases
of a traumatized wound with poor sealing properties, it is
possible to close it by a suture using usually a 10-0 nylon.
SPECIFIC COMPLICATIONS OF
LASER-ASSISTED CATARACT SURGERY
Loss of Suction During Docking
Loss of suction during docking leads to interruption of
the laser procedure. It is usually possible to dock the patient
again and repeat and conclude the laser procedure. For a
second laser attempt, some surgeons recommend enlarging
the diameter of the capsulotomy to keep the first laser cuts
inside of the circular capsulotomy.
Conjunctival and Subconjunctival
Hemorrhage
Bleeding of conjunctival and episcleral vessels occurs in
a significant number of eyes after docking. It is caused by
a vacuum applied by a suction ring. It is mostly a cosmetic
problem, but it can increase the inflammatory response to
the surgery.

Corneal Epithelial Edema
Sometimes, mainly after repeating docking, epithelial
edema is seen after the laser part of the procedure. The
edema makes the intraocular part of the procedure more
challenging because of the decreased visualization of intra-
ocular structures. We see this complication in less than 1%
of cases and there were no cases with edema so severe as to
require epithelial abrasion during our first 1000 cases.
Epithelial Erosion
An epithelial erosion can arise from the contact of the
laser interface with the corneal surface.
Pupil Constriction
Pupil constriction is a consequence of laser energy
interaction with intraocular tissue. We observed a certain
degree of pupil constriction in up to 50% of eyes. Again
this makes the intraocular surgery more challenging. An
intraocular injection of preservative-free lidocaine and
mainly preservative-free epinephrine enlarges the pupil
effectively in most cases. Some surgeons use nonsteroidal
anti-inflammatory drops before the laser part to decrease
pupil constriction. We also effectively used intraocular
epinephrine injection before the laser part. When the drug
is injected before docking by a 30-gauge needle directed
through the corneal limbus into the anterior chamber, the
needle channel is self-sealing and the pupil constriction
does not appear.
Incomplete Capsulotomy
Whenever the central capsule is not free after the laser
procedure, there are several options as to how to proceed.
Usually, a careful manipulation with a capsulorrhexis for-
ceps is recommended to peel the central capsule off, avoid-
ing the radial capsular tear. The author usually go in right
away with a phaco tip and aspirate the central capsule as
described in section 2b of femtosecond laser part of surgery
description.
Capsular Block Syndrome
It is caused by gas bubbles in the capsular bag created
during laser fragmentation or by fluid injected into the
capsular bag during hydrodissection. When the gas or
fluid pushes the lens material up toward the capsulotomy
opening, it can close the bag and subsequent gas bubble
formation or injection of fluid can rupture the capsule. In
the early days of laser-assisted cataract surgery, there were
cases when a laser lens fragmentation was performed as the
first surgical step before the capsulotomy. The gas bubbles
in the capsular bag ruptured the capsule and ejected
the lens material into the vitreous cavity.13 Therefore,
Femtosecond Laser-Assisted Cataract Surgery  135
the laser capsulotomy is performed before the laser lens
fragmentation.
CONTRAINDICATIONS OF LASER-
ASSISTED CATARACT SURGERY
Besides the contraindications of cataract surgery, the
contraindications of laser-assisted cataract surgery include
perforation of the globe and globes at risk of perforation
because the docking procedure applies pressure on the eye
globe. Opaque corneas preventing the effective delivery
of laser procedure is a contraindication for this surgical
approach, but it was proven that it is possible to successfully
perform laser capsulotomy and lens fragmentation even
through semitransparent corneas. Bone trauma around
the eye is another contraindication. Also a noncoopera-
tive patient might be a contraindication, but it is possible
to perform laser-assisted cataract surgery under general
anesthesia.
CHALLENGING CASES
Small Pupil and Posterior Adhesions
Whenever the pupil is equal to or smaller than intended
or the pupil is deformed by a posterior adhesion extending
into the intended capsulotomy area, it is not possible to
perform laser capsulotomy. It is possible to perform 1 or
more side port incisions and break the adhesion or manu-
ally dilate the pupil. It is possible to apply a suction ring
dock to the patient when self-sealing side port incisions are
in place. It is also possible to fill the anterior chamber with
viscoelastic to keep the pupil wide and perform the laser
capsulotomy and lens fragmentation with the viscoelastic
material in the chamber.
Corneal Opacities
Mild corneal edema for instance in cases of advanced
Fuchs endothelial dystrophy is not a contraindication for
laser-assisted cataract surgery and it is possible to success-
fully perform the laser procedure through such corneas.
The subsequent intraocular surgery is shorter and requires
less ultrasound energy compared to a conventional ultra-
sound cataract surgery. Generally mild corneal opacities are
not contraindication for this procedure but possess a higher
risk of incomplete capsulotomy. The author of this chapter
has performed several successful laser capsulotomies and
lens fragmentation through semitransparent corneas.
136  Chapter 10
Figure 10-10. Laser capsulotomy performed in the presence
of a corneal ring in the eye with keratoconus. Note the perfect
centration of the capsulotomy inside of the area determined by
a corneal ring.
Keratoconus
It is possible to perform laser-assisted cataract surgery
through a cornea in keratoconus cases unless there are
severe corneal scars or there is a risk of corneal perforation.
Corneal Ring
The presence of a corneal intrastromal segment is not
a contraindication for laser-assisted cataract surgery. It is
possible to place a laser capsulotomy to the space deter-
mined by inner ring edge and perform both capsulotomy
and lens fragmentation. Both the capsulotomy diameter
and fragmentation diameter are limited by the inner diam-
eter of the ring (Figure 10-10).
Posterior Laser Capsulotomy
It is possible to perform a laser capsulotomy on a poste-
rior capsule. We have performed a case where laser-assisted
cataract surgery was performed on an eye with silicone oil
in the vitreous cavity. After the cataract was removed, we
docked the patient back under the femtosecond laser and
performed posterior capsulotomy of a diameter of 3.5 mm.
After the posterior central capsule was extracted, the sili-
cone oil was removed from the eye through the main inci-
sion with aid of an irrigating bimanual cannula introduced
through a side port incision into the vitreous cannula. The
main incision was kept open by a spatula. After the oil was
removed, an IOL was introduced into the capsular bag with
the irrigating cannula maintaining the anterior chamber
and pressurizing the eye globe.
Logistics and Economics
The challenges to incorporate laser-assisted cataract
surgery include investing in laser technology, building an
operating theatre with high demand for temperature and
humidity stability, accepting a more complex 2-step surgi-
cal process with per procedure fee and with longer overall
time, and requiring more staff. To be able to economically
justify the high investment into this technology, we aimed
not only to make the surgery more advanced but also to
increase the volume of cataract surgeries performed per
hour. There are basically 2 models to determine how to
incorporate a femtosecond laser into the cataract surgery
facility. The first is to place the laser right into the operating
room for intraocular surgery. The potential advantage is a
minimal manipulation with the patient in between the laser
and intraocular part of surgery. After the laser part of the
surgery, the patient bed is swung sideways and the intra-
ocular surgery starts right away. We decided for the second
possibility to place the laser into a separate operating room
adjacent to the room for intraocular surgery. In fact, we
built a separate room for the laser on the side of our already
existing operating rooms.
Wish List for the Future
The author wishes the laser technology of the future will
come at a more reasonable price possibly with no per pro-
cedure fee. The laser device should be compact and possibly
mobile in between clinics with low maintenance require-
ments. It should optimally be a multipurpose platform not
only for laser cataract surgery but also for LASIK flap cre-
ation, keratoplasties, and possibly glaucoma surgery appli-
cation. The author would welcome a noncontact instrument
with 3D eye tracker delivering the laser spots inside of the
eye without a need for docking and physical contact of
mechanical laser parts with the eye. The fragmentation pat-
terns should enable for ultrasound-free surgery in majority
of cases. Let us see where the market and development will
take us in the near future. Initial reports explore the possi-
bility to reverse cataract formation14 or presbyopia treating
the crystalline lens directly with a femtosecond laser.
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MC. Comparison of intraocular lens decentration parameters
after femtosecond and manual capsulotomies. J Refract Surg.
2011;27(8):564-569.
6. Miháltz K, Knorz MC, Alió JL, et al. Internal aberrations and
optical quality after femtosecond laser anterior capsulotomy in
cataract surgery. J Refract Surg. 2011;27(10):711-716.
7. Abell RG, Kerr NM, Vote BJ. Femtosecond laser-assisted cata-
ract surgery compared to conventional cataract surgery. Clin
Experiment Ophthalmol. 2013;41(5):455-462.
8. Takács AI, Kovács I, Miháltz K, Filkorn T, Knorz MC, Nagy
ZZ. Central corneal volume and endothelial cell count fol-
lowing femtosecond laser-assisted refractive cataract surgery
compared to conventional phacoemulsification. J Refract Surg.
2012;28(6):387-391.
9. Wang J, Sramek C, Paulus YM, et al. Retinal safety of near-infra-
red lasers in cataract surgery. J Biomed Opt. 201228;17(9):95001-1
Femtosecond Laser-Assisted Cataract Surgery  137
10. Nagy ZZ, Ecsedy M, Kovács I, et al. Macular morphology assessed
by optical coherence tomography image segmentation after fem-
tosecond laser-assisted and standard cataract surgery. J Cataract
Refract Surg. 2012;38(6):941-946.
11. Friedman NJ, Palanker DV, Schuele G, et al. Femtosecond laser
capsulotomy. J Cataract Refract Surg. 2011;37(7):1189-1198.
12. Conrad-Hengerer I, Hengerer FH, Schultz T, Dick HB. Effect of
femtosecond laser fragmentation of the nucleus with different
softening grid sizes on effective phaco time in cataract surgery.
J Cataract Refract Surg. 2012;38(11):1888-1894.
13. Roberts TV, Sutton G, Lawless MA, Jindal-Bali S, Hodge
C. Capsular block syndrome associated with femtosec-
ond laser-assisted cataract surgery. J Cataract Refract Surg.
2011;37(11):2068-2070.
14. Kessel L, Eskildsen L, van der Poel M, Larsen M. Non-invasive
bleaching of the human lens by femtosecond laser photolysis.
PLoS One. 2010;5(3):e9711.

The Role of Femtolaser in Cataract
Surgery and Early Clinical Results
Zoltan Z. Nagy, MD, PhD
Femtolasers have been recently introduced—having had
a great success in corneal surgery—into the surgery of
the crystalline lens. The most important indications and
features are perfectly centered and sized capsulotomy, liq-
uefaction of softer lenses, fragmentation of harder lenses to
help chopping of the cataractous lens without phaco energy,
and lastly to create corneal wounds in any position and any
size and also to manage preoperative astigmatism using
arcuate incisions at the desired depth within the cornea.
Because of controlled steps in cataract surgery, wide accep-
tance and use is to be expected. Early clinical results are
discussed in this chapter.
FEMTOSECOND CATARACT SURGERY
Femtolasers are operating at high energy levels and very
short pulses (in the femtosecond range). The usual wave-
length is 1053 nm, Nd–glass is the active laser medium, and
this wavelength operates in the near infrared range of elec-
tromagnetic spectrum. The depth of the femtolaser effect
can be precisely controlled and focused within the eye;
therefore, very precise cuts can be achieved. During appli-
cation within the cut, microplasm is created in the order of
1.0 μm. The surgeon may observe in the operating micro-
scope a fine line, consisting of whitish gas bubbles within
the cut plane. The laser impulses can be placed in any plane;
therefore, horizontal, perpendicular, and any kind and size
of cut can be created. These features can be very well used
in corneal surgery and also with surgery of the crystalline
lens. Femtolasers until recently were used only for corneal
surgery, but based on the technical development carried out
- 139 -
11
by researchers at Alcon-LenSx, femtolaser surgery of the
crystalline lens has been approved by the FDA since 2010
for capsulorrhexis, lens fragmentation and liquefaction,
creating corneal wounds, and lastly for creating arcuate
incisions to control preoperative astigmatism (Figure 11-1).
The first ever human treatment in the world was performed
in August 2008 in Semmelweis University, Budapest, by Dr.
Zoltan Z. Nagy.1
It is still debated what are the most important advan-
tages of femtolaser refractive cataract surgery over manual
phacoemulsification. The most important features can be
seen next, but in summary based on previous experiences,
one can conclude exact diameter and central position of
capsulorrhexis, reduction in phacoemulsification energy,
compact corneal wounds in the desired position and
size, much higher predictability compared to traditional
phacoemulsification, and the surgeon is able to control
with micrometer exactness all critical steps of cataract
surgery.1,4 These issues became more important with the
advent of premium lenses, which require more precise steps
in the surgical cascade. For example, if capsulorrhexis is
larger than the desired 5.00 mm or it is decentered, shift
of the implanted posterior chamber lens (PCL) may result
in myopic/hyperopic refractive change and increase in
higher-order aberrations, causing glare, and halo effect.4,5,7
Because ophthalmologists now operate on younger and
younger patients, quality of vision, the ability to perfectly
see for far and near distances, exerts tremendous pressure
on ophthalmologists. These surgical requirements can be
achieved only with perfect technology.
For the treatment of the crystalline lens, the surgeon may
choose a cylindrical pattern or a cross-pattern treatment.
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 139-146).
© 2014 SLACK Incorporated.
140  Chapter 11

With the creation of the corneal wound, one can use

many parameters: wound structure (uniplanar, biplanar,
multiplanar), and the length and width of the wound;
moreover, the position of the wound can be also custom-
ized (upper or temporal incisions, etc) for the convenience
of the surgeon.
It is very important to note that the corneal wound has
micro bridges of tissue, so it does not open upon creation.
The surgeon may perform it within the operating room
(OR) or outside it hours before. This is an important factor
because if the femtolaser is used by many surgeons in dif-
ferent ORs, it is recommended to have a separate laser room
in order to use it efficiently.

Indications and Inclusion and

Exclusion Criteria
Indications for lens liquefaction:
1. Refractive lens exchange, mainly for high myopia and
high hyperopia
2. Cataract grading max. 2.0 according to the LOCS sys-
tem, or age up to 50 years
3. Traumatic cataract (lens just starting to get opaque) age
below 50 years
Figure 11-1. The LenSx femtolaser. Indications for lens fragmentation:
1. Cataract up to 4.5 grade, and above 1.5 grade
Cylindrical pattern means concentric rings starting from 2. No age limit, but in younger patients, usually liquefac-
the back of the crystalline lens (about 400 mm away from tion is better
the posterior capsule) toward the anterior capsule. The 3. Traumatic cataract, when the nucleus seems harder
surgeon constantly controls the position of the laser beam
Contraindications:
within the crystalline lens. The cylindrical pattern is rec-
ommended for up to grade 2 lenses according to the LOCS 1. Nondilating pupil
system. The aim of this is to liquefy the central lens material Relative contraindications:
and then the surgeon is able to aspirate the lens material 1. Brown or black cataract (only for rhexis and corneal
using only the irrigation/aspiration (I/A) program of the wound)
phacoemulsification machine. This is meant for refractive
2. White cataract (only relative contraindication, because
lens exchange, especially in younger patients with high
the capsulorrhexis can be performed, but cuts cannot
myopia and hyperopia or in patients where the restoration
be made within the white lens material [corneal wound
of accommodation is needed.
is perfect])
The cross pattern is recommended in harder nuclei up
to +4.0 grade according to the LOCS system. The 4 cuts (to Sequence of the femtolaser procedure:
form 4 quadrants within the lens) are necessary, and the 1. Patient selection
surgeon may choose, of course, 6 or 8 cuts (cake pattern). 2. Consent
The 4 cuts are very useful to “crack” the nucleus without
using any phaco energy (no need to make a groove with 3. Patient head positioning
the phaco tip using ultrasound energy) at the beginning 4. Drop anesthesia
of the surgery. After this, phacoemulsification proceeds as 5. Capsulorrhexis
with traditional phacoemulsification. Recently, the hybrid
pattern is also used for harder nuclei; that is, in the central 6. Lens liquefaction or fragmentation
3.5-mm zone, a liquefaction is used parallel with the frag- 7. Astigmatism correction (arcuate incisions at 80%
mentation. During the first step, the surgeon removes the depth)
central part and then chops the lens more easily. The last 8. Corneal wound
pattern became popular quickly.
 The Role of Femtolaser in Cataract Surgery and Early Clinical Results  141

Figure 11-2. The screen for the surgeon. Note the corneal
wounds, the astigmatic incisions. On the right upper part,
the OCT identifies the endothelial layer, the anterior capsule
(highest and lowest point); on the lower part of the image, OCT
identifies the cut within the crystalline lens (yellow area).

Patient Selection and Preparation

B
It is very important that the patient be cooperative, have
a positive attitude, understand the importance of laser
treatment, and should accept the possible problems using
this technology. The ideal patient should be able to tolerate
some pressure during the treatment, not too anxious and
able to look into the fixation light of the operating micro-
scope or in the patient interface, able to rest for a couple
of minutes, have no cataract (refractive lens exchange), or
have a nuclear cataract grading less than 4.0 according to
the LOCS system. Besides slit lamp examination, the use
of Pentacam (Oculus) is recommended because the density
of the crystalline lens can be preoperatively assessed eas- Figure 11-3. The proprietary image-guided system allows the
surgeon to take a (A) preoperative OCT image and position the
ily. Also the surgeon gains important information about
planned incisions and photolysis patterns on the patient’s eye.
the anatomical data of the eye. The measurement of lens (B) The blue and yellow overlays represent the lens photolysis
density is also possible with the built-in optical coherence and capsulotomy patterns. The red represents the corneal inci-
tomography (OCT), but it is recommended only when there sions. Size and position of all patterns can be preprogrammed
is no Pentacam available. and adjusted for ultimate surgeon control.
The new high-definition OCT (HD-OCT) provides
significantly improved imaging and is also suitable for
assessing the lens density. Of course, it is still advised to free-floating capsule can be achieved and less phacoemul-
assess density preoperatively to have a surgical plan before sification energy is needed. The wound structure is also
entering the OR. better achieved.

Laser Docking and Coupling Image-Guided Alignment of Laser

The femtolaser treatment is performed in a supine posi-
tion. It is most important to achieve a resting position
and the eye should be absolutely horizontal. If this is not
achieved, there will be a tilt of the eye and a tilt within the
crystalline lens, and the surgeon will not be able to fix the
patient interface (PI) properly. A firm head rest is recom-
mended to avoid downward head movement during femto-
laser procedure.
The new SoftFit patient interface by Alcon consisting
of a new interface with a soft contact lens provides easier
docking; there are no corneal folds. In 95% of the cases, a
Treatment
One of the most important features of the commercially
available femtolasers is the built-in OCT imaging system.
It is important to plan all treatment details, have a safe
distance from posterior and anterior capsule, and achieve
a perfect corneal incision. The OCT examination is per-
formed after having centered the eye. After inserting the PI,
the computer projects circles and lines (limbal area, capsu-
lotomy, corneal wounds) on the surface of the eye (Figures
11-2 and 11-3). The surgeon controls the central position
of the projected circles and lines and then performs the
142  Chapter 11
first OCT measurement. As the first step, the surgeon
identifies the anterior and posterior capsule and plans the
capsulotomy. During the second step, the surgeon identifies
the anterior and posterior capsule and manually sets the
machine where the fragmentation within the lens should
be. During the third OCT measurement, the corneal inci-
sions are planned and can be modified. After accepting the
treatment parameters, all data are transferred to the com-
puter of the femtolaser and the treatment can be started, by
pressing down the treatment pedal. The whole femtolaser
treatment usually does not exceed 50 seconds.
Laser Steps
The laser steps are as follows:
● Cut in the anterior capsule (capsulorrhexis).
● Cut in the lens (cylindrical or cross pattern).
● Cut in the cornea (uniplanar, biplanar, multiplanar, or
arcuate).
Cataract Surgery
As a first step, the surgeon identifies the corneal wounds
and opens them with a blunt spatula. Thereafter the anteri-
or chamber should be filled with viscoelastic material. The
deepest cut within the lens should be sought for and identi-
fied and possibly lifted with a rhexis needle (cystotome) or
rhexis forceps. The contour of the femtolaser cut should be
meticulously followed and the round shape anterior capsule
can be removed in this manner. Simply pulling out with
abrupt hand movement can cause an anterior tear, which
might lead to anterior and posterior capsular damage.
Small tags can occur, especially during the learning curve.
After removing the capsule, a slow hydrodissection should
be performed. It should be carried out slowly and gently
because gas bubbles may appear within the crystalline lens
after fragmentation; with slow hydrodissection the gas
exits through the anterior capsule without a problem. With
abrupt hydrodissection, a blockage syndrome may result,
causing rupture of the posterior capsule. I never had such
a problem, and with cautious technique, it can be avoided
in 100% of cases. After successful hydrodissection, the
surgeon enters the eye with the phaco tip and the chopper.
It is advised to occlude the lens near to the perpendicular
fragmentation line with 300 mm Hg and to chop it into
2 pieces with the chopper, then turn the lens and repeat
the movement with the other fragmentation line. Having
4 quadrants of the nucleus, they can be easily removed
using minimal phacoemulsification energy and time, so
the cumulative delivered energy (CDE) can be minimized.
After nucleus removal, the cortex should be removed with
I/A similar to manual phacoemulsification. Sometimes, a
larger epinucleus stays like a “bowl” that can be removed
with the epinucleus setting of the phaco machine or simply
with the I/A. The PCL implantation is similar to previous
surgical technique. At the end of surgery, the wound should
be checked; most of the cases do not require hydration
because the wound itself is self-sealing. If there was a tear
or other surgical trauma, that case might require hydration.
According to the European Endophthalmitis Study, intra-
cameral antibiotics should be used to avoid postoperative
intraocular complications.
In the case of softer lenses, after removing the ante-
rior capsule, hydrodissection is usually not required and
the central nucleus can be easily aspirated using only the
I/A tip. Anterior chamber depth (ACD) should be closely
monitored and maintained during surgery especially with
high myopes and sometimes hyperopes to ensure safety.
It is especially important in younger patients operated
with topical anesthesia. They may be anxious and exerting
pressure with the speculum, consequently causing higher
intraocular pressure.
I would like to emphasize the so-called rock-and-roll
technique: gentle hydrodissection, then gently push the
nucleus up and down (rock), and to move (roll) a bit to allow
the intralenticular gas bubble to enter the anterior chamber,
preventing capsular blockage syndrome. In very soft and
very hard lenses, hydrodissection is mandatory!
CLINICAL RESULTS OF
FEMTOLASER CATARACT SURGERY
Anterior Capsulotomy
Anterior capsulotomy was initially evaluated in ex vivo
porcine eyes; the first clinical series involved patient’s eyes
also. The authors found that an intended 5.00-mm capsu-
lorrhexis in porcine eyes became 5.88 +/−0.73 mm using the
standard manual technique, while 5.02 +/−0.04 mm using
the femtolaser technology for capsulotomy. In human eyes,
femtolaser technology achieved all capsulotomies within
+/−0.25 mm of desired; on the other hand, with the manual
technique it was achieved only in 10% of the eyes. Using
manual standard continuous curvilinear capsulorrhexis
(CCC) technique, the diameter of the achieved capsulor-
rhexis was on average within +/−1.00 mm of the intended
diameter.1
Capsulorrhexis is very important regarding the final
refractive results of cataract surgery. Until now, the manual
technique was the only one available. Therefore, not too
much was written about the significance of perfectly cen-
tered and exact diameter of the capsulorrhexis. If the rhexis
is larger than the intended diameter, it might cause anterior
or posterior shift or tilt of the implanted PCL. The effective
lens position (ELP) is a very important issue in modern
cataract surgery, especially with the advanced technology
intraocular lens (IOL). ELP is derived from anatomical
characteristics of the eye like ACD, the diameter of the
 The Role of Femtolaser in Cataract Surgery and Early Clinical Results  143

capsulorrhexis, and different IOL formulas. The key ele- overlap (p = 0.002) were significant predictors of horizontal
ment is the capsulorrhexis size.2 According to studies by decentration of IOLs.4
Cionni, a 0.5-mm difference in IOL position may result In another study, anterior capsulotomy was performed
in approximately a 1.00-D change in refractive error. A with the Alcon-LenSx femtosecond laser in 54 eyes and a
reproducible, well-centered, and properly positioned cir- manual CCC was performed in 57 eyes. The circularity
cular capsulorrhexis that overlaps the optics of the IOL and the exact area of the capsulotomy and IOL decentra-
360 degrees is a prerequisite for good postoperative refrac- tion were determined using Photoshop CS4 Extended
tion or, in other words, predicting the refractive difference (Adobe Photoshop Systems Inc) 1 week and 1 month post-
between intended and achieved refraction.3 As mentioned operatively. Circularity was statistically significantly better
in an early study performed in the Semmelweis University, in the femtosecond laser group (p = 0.032) and there was
Budapest, Hungary, the authors achieved the desired rhexis significantly less incomplete overlap of capsulotomies in
diameter in 100% of the treated eyes with the femtolaser the manual rhexis group compared to the femtosecond-
capsulotomy technique.1 treated eyes (28% of eyes versus 11%; p = 0.033).5
In another prospective, nonrandomized clinical study
in the Semmelweis University, Budapest, Hungary, 20 eyes Types and Question of Lens
were included that had a 4.5-mm capsulotomy performed
by the femtolaser (Alcon-LenSx) and another 20 eyes had a Fragmentation
4.5-mm manual capsulorrhexis. ACD and AL (axial length)
The Alcon-LenSx femtosecond laser offers different
were determined using the LenStar Optical Biometry
types of lens fragmentation. In soft lenses grading less
(Haag-Streit AG) at 1 week, 1 month, and 1 year postop-
than 2.0 according to the LOCS system, a 5.0-mm central
eratively. A significant difference in variability was found
liquefaction is recommended, creating concentric rings
of ACD:AL ratio and a significant difference was found
(cylindrical pattern) within the nucleus of the crystalline
between the 2 groups with reduced variability in ELP in the
lens. This possibility is especially important in refractive
femtolaser-treated eyes as compared to the manual group
lens exchanges and if the patient’s age is less than 45 years.
during the whole follow-up period.4
In nuclei grading over 2.0, a fragmentation of the lens
A similar study was performed using different types
nucleus is recommended. This can be a cross pattern
of IOLs in a prospective single-surgeon study. The vari-
(2 perpendicular incisions within the lens) or can be cus-
ability and predictability in ELP and refractive outcomes
tomized with an increased number of cuts. They are called
were compared between femtolaser-treated and manually
cake or pizza pattern fragmentation (6 to 8 cuts). More cuts
created capsulorrhexis eyes. During the study, monofocal
are not recommended because during chopping more frag-
(hydrophobic, acrylic 1-piece) and multifocal (hydrophobic
mentation lines cannot be used effectively.
acrylic 1-piece) PCLs were implanted. Results showed better
Presently, a hybrid pattern is preferred, using a central
predictability and variability of ELP for all types of IOLs
3.0-mm diameter liquefaction and peripheral fragmenta-
when the capsulotomy was performed by the LenSx fem-
tion lines. With this method, the surgeon is able to spare
tolaser. In summary, it can be concluded that laser capsu-
even more phaco energy and phaco time, thus increasing
lotomy has positively influenced the predictability of ELP.4
the safety of the method.
The liquefaction and fragmentation diameter area
Anterior Capsuolotomy Circularity should not be more than 1.0 mm larger than the capsulor-
and Posterior Chamber Lens rhexis diameter because the posterior surface of the crystal-
line lens surface has a concave shape. With longer fragmen-
Centration tation lines, the possibility to harm the posterior capsule
increases. The built-in OCT provides safety to control the
The authors performed 2 studies in the Department of
distance from the posterior capsule. Presently a 500- to
Ophthalmology, Semmelweis University, in order to deter-
700-μm safety distance is recommended. The distance is
mine the exactness of circularity (how round is the capsu-
set automatically by the LenSx femtolaser. In the case of
lotomy) and the effect on PCL centration postoperatively.
lens tilt, the surgeon should check it meticulously because
The first study showed that femtosecond laser-performed
in some parts, the fragmentation line may be closer to the
anterior capsulotomy was more regularly shaped and
posterior capsule. If the surgeon increases the length of
showed better centration and better capsule/IOL overlap
the fragmentation line, with the effective 500- to 700-μm
compared to manual capsulorrhexis.4 The vertical diameter
safety distance from the peripheral posterior capsule, in the
and horizontal IOL decentration of the manual rhexis were
central part, this distance might increase to 1.5 mm. In that
statistically significantly higher. There were also signifi-
case, effective chopping is difficult in the central area with-
cantly high values of capsule overlap and better circularity
out using phacoemulsification and the advantage offered
values in the femtosecond laser-performed capsulotomies.
by the femtosecond laser might be partly lost. Therefore,
Univariate analysis showed that the type of capsulorrhexis
(femtosecond over manual technique) (p < 0.01) and capsule
144  Chapter 11
the length should not be much longer than the capsulotomy
diameter.
Energy for Phacoemulsification
The comparison of femtosecond laser fragmentation
with the cross pattern and “quick chop” traditional phaco-
emulsification technique resulted in a 43% reduction in
CDE and a 51% reduction in phacoemulsification time
using the Infiniti (Alcon Laboratories Inc) phacoemulsi-
fication machine. During the study, there was no compli-
cation with either the femtolaser pretreatment or during
phacoemulsification of the pre-fragmented nucleus.1 With
the newer fragmentation software, more CDE sparing is
expected, increasing the safety of cataract removal, regard-
ing endothelial cell loss and cystoid macular edema.
In another prospective, nonrandomized study, the
authors evaluated reduction of phacoemulsification time
and power after femtosecond laser lens treatment and tradi-
tional phacoemulsification. Sixty eyes of 60 patients in each
group were included. Mean CDE was significantly reduced
in the femtosecond laser group and there was a 25% reduc-
tion in endothelial cell loss compared to the traditional
manual phacoemulsification group.6
Corneal Wounds and Arcuate Incisions
to Control Preoperative Corneal
Astigmatism
Corneal wounds with perfect structure and dimen-
sion are of great importance to prevent postoperative
infection and minimize surgically induced astigma-
tism (SIA). Wound characteristics are also important in
IOL selection—especially for toric and multifocal PCLs.
Manual, blade-created wounds may have imprecise tunnel
length and structure and often require stromal hydra-
tion at the end of surgery. Manual wounds might also be
unstable at low intraocular pressure, allowing bacteria into
the eye from the conjunctival sac, causing vision threaten-
ing endophthalmitis. Therefore, possibilities offered by the
femtolaser like precise wound geometry and architecture
with better precision and consistency promise a better seal
without the need for postoperative stromal hydration.
Limbal relaxing incisions are typically created using a
handheld diamond knife. The real depth of the incision is
difficult to control with the manual technique. Surgeons
may use corneal marks for better placement of incisions.
Manual incisions might be imprecise in both incision
depth and architecture. The Alcon-LenSx femtosecond
laser uses an image-guided capability, which is able to
control the corneal thickness measurements, the shape,
placement, incision length, width, and depth (percentage of
corneal thickness). The procedure is computer controlled,
predictable, and precise. The surgeon can immediately
open the incision after femtolaser pretreatment or can wait
until the next postoperative day. Using this, the surgeon can
take into consideration the SIA and can topographically
control how deep he or she should open the premade cor-
neal incisions at the slit lamp in the office. So, the effect of
femtolaser-created arcuate corneal incisions can be titrated
in order to reach the optimal effect as regards the preopera-
tive corneal astigmatism.
Refractive Outcome
The authors performed a prospective, nonrandomized
study in the Semmelweis University, Budapest, Hungary,
in order to determine the internal aberrations in eyes
treated with the femtosecond laser. Results were compared
to manual phacoemulsification eyes. Femtolaser anterior
capsulotomy was performed in 48 eyes and manual CCC
in 51 eyes. Results revealed that the femtolaser capsulotomy
induced significantly less internal aberrations as measured
by the Nidek optical path difference scan aberrometer
(Nidek Inc).7 Main outcome measures were postoperative
visual acuity (uncorrected, best spectacle corrected), resid-
ual refraction, ocular and internal aberrations (the lower
the value, the better the result), Strehl ratio (the higher, the
better, to quantify the effect of wavefront aberration on
image quality = quality of vision), and modulation transfer
function (MTF) to measure the sharpness of the image
created by the IOL (the higher the better). There was no sta-
tistically significant difference found regarding postopera-
tive refraction, uncorrected, and best spectacle-corrected
distant visual acuity. The femtosecond-treated eyes, how-
ever, showed significantly better quality of vision postop-
eratively. The femtosecond-treated eyes had lower values of
intraocular vertical tilt (Z1-1) and coma aberrations (Z3-1),
higher Strehl ratios, and higher MTF values at all measured
cycles per degree (p < 0.05).7 In summary, femtolaser-
created anterior capsulotomy eyes showed better quality of
vision and significantly less induced internal aberrations as
compared to traditional manual capsulorrhexis.
Endothelial Effects
The authors examined the effect of femtolaser treatment
on corneal thickness, corneal volume stress index, and
endothelial density and found significantly better results
in the early postoperative period in favor of the femtolaser-
treated group regarding corneal thickness (580 versus
610 mm) (p = <0.05). Volume stress index was also found
to be statistically significantly lower among the femtola-
ser-treated eyes, and the same was found for endothelial
density.8 The presumed reason behind this is the shorter
phacoemulsification time with less CDE.
 The Role of Femtolaser in Cataract Surgery and Early Clinical Results  145
Macular Effects
In another study, the authors performed the macu-
lar thickness study.9 Twenty eyes of 20 patients received
femtolaser treatment and 20 eyes of 20 other patients
received traditional phacoemulsification with manual
CCC. Macular thickness and volume were assessed by
OCT (Zeiss GmbH) 1 week and 1 month postoperatively.
Outcome measurements were retinal thickness assessed by
the OCT in 3 macular areas and total macular volume at
1 week and 1 month postoperatively. Secondary outcome
measures were changes in retinal thickness at 1 week and
1 month postoperatively in comparison with preoperative
retinal thickness values. Multivariable statistical modeling
showed significantly less macular thickness in the inner
retinal ring in the femtolaser-treated group after adjusting
for age and preoperative thickness across the whole time
course (p = 0.002). In the traditional phacoemulsification
group, the inner macular layer was significantly thicker
at 1 week. After 1 month, this difference disappeared (was
no longer statistically significant).9 Thus, regarding safety
issues, femtosecond laser–assisted cataract eyes do not dif-
fer regarding macular thickness compared to traditional
ultrasound phacoemulsification; on the other hand, results
are somewhat better regarding the thickness of the inner
retinal layer during the first week following surgery.
Ergonomics of the Femtosecond Laser
It is a very important issue where to place the femtosec-
ond laser unit: in the OR or outside of it. The LenSx laser
is designed to be utilized either in an ambulatory surgery
(outside the OR) or within the OR. The reason behind it
is that corneal incisions created by the femtolaser are self-
sealing pre- and postoperatively as well. One to 3 patients
can be pretreated if pupillary dilation is sufficient for the
cataract surgeon. In that way, the femtolaser can serve
multiple surgeons. If it is placed in the OR, it can serve only
one surgeon.
It should be noted that pupil should be larger than
6.0 or 7.0 mm. Because the shock wave of the laser may
affect the edge of the iris, postlaser pupillary constriction
might occur. More frequent dilation drops and a nonste-
roidal anti-inflammatory drug eye drop are recommended
during the preoperative period. Presently, the femtolaser
pretreatment lasts 45 to 60 seconds. If the laser is placed
within 10 m from the OR, walking the patient into the
main OR does not slow down the surgical flow. On the
other hand, the previously performed corneal incision,
capsulorrhexis, and lens fragmentation spare surgical time
and instrumentation also. So, after the learning curve the
patient flow may eventually speed up.
Conclusions and Future Possibilities
The LenSx femtolaser currently is approved for cor-
neal incisions (any kind of wound and arcuate incisions),
capsulotomy, and lens fragmentation or liquefaction. The
femtolaser replaces the manually performed incisions dur-
ing cataract surgery, allowing for more precise, more
predictable, and more consistent results for surgeons and
patients. It is an OCT image-guided, surgeon-customizable,
computer-controlled laser system. Studies of the authors
have demonstrated exact diameter size of capsulotomy,
better centration and a better circularity, better ELP, and
less internal aberration for the femtolaser-treated eyes.
Moreover, the energy and time required for phacoemulsi-
fication decreased significantly and decreased endothelial
cell loss was experienced, and macular studies confirmed
good safety of the method; there was no deleterious effect of
the femtolaser regarding postoperative macular thickness.
In the femtolaser experience, new developments are to be
expected, like new phacoemulsification tips, smaller inci-
sion wounds, and new IOL types. In the future, combined
machines may appear that are able to simultaneously treat
the lens and the cornea. Femtolaser cataract surgery is in its
infancy, but it is a very promising technology for surgeons
and patient benefit.
SUMMARY
Femtolaser treatment of the crystalline lens increases
safety, efficacy, and predictability of the surgery. Surgical
skill and wisdom are still needed to avoid possible
complications that might arise during lens surgery. During
well-prepared surgeries (thoughtful patient information
and selection, proper PI insertion, well-designed and
performed capsulotomy, lens fragmentation/liquefaction,
and corneal wound and astigmatism correction), the safety
of refractive cataract surgery increases and all advantages of
the premium lenses can be achieved to benefit our patients.
Pricing is an important factor in how quickly the procedure
will spread, but with the aging population and the increas-
ing number of cataracts, and clear lens surgery, wide accep-
tance and use is expected in the near future.
REFERENCES
1. Nagy ZZ, Takacs A, Filkorn T, Sarayba M. Initial clinical evalua-
tion of intraocular femtosecond laser in cataract surgery. J Refract
Surg. 2009;25:1053-1060.
2. Cekic O, Batman C: The relationship between capsulorrhexis size
and anterior chamber depth relation. Ophthalmic Surg Lasers.
1999;32:1661-1666.
3. Hill WE. Hitting emmetropia. In: Chang D, ed. Mastering
Refractive IOLs: The Art and Science. Thorofare, NJ: SLACK
Incorporated; 2008:533-534.
146  Chapter 11
4. Nagy ZZ, Kranitz K, Takacs AI, Miháltz K, Kovács I, Knorz
MC. Comparison of intraocular lens decentration parameters
after femtosecond and manual capsulotomies. J Refract Surg.
2011;27:564-569.
5. Kranitz K, Takacs A, Mihaltz K, Kovács I, Knorz MC, Nagy ZZ.
Femtosecond laser capsulotomy and manual continuous curvi-
linear capsulorrhexis parameters and their effects on intraocular
lens centration. J Refract Surg. 2011;27:558-563.
6. Knorz MC, Nagy ZZ. Reduction in mean cumulative dissipated
energy following lens liquefaction with an intraocular femtosec-
ond laser. Poster presented at AAO Annual meeting October 2011;
Orlando, Florida, United States.
7. Mihaltz K, Knorz MC, Alio JL, et al. Internal aberration and
optical quality after femtosecond laser anterior capsulotomy in
cataract surgery. J Refract Surg. 2011;27:711-716.
8. Takács AI, Kovács I, Miháltz K, Filkorn T, Knorz MC, Nagy ZZ.
The effect of femtolaser cataract surgery on the cornea. J Refract
Surg. (in press).
9. Ecsedy M, Mihaltz K, Kovacs I, Takács A, Filkorn T, Nagy ZZ.
Effect of femtosecond laser cataract surgery on the macula.
J Refract Surg. 2011;27:717-722.

Femtocataract Surgery With
B-MICS Sub 1 mm
Joaquín Fernández Pérez, MD; Almudena Valero Marcos, MD;
María José Pérez Morales DNP; and Francisco Javier Martínez Peña, OD
Cataract surgery is the most commonly performed eye
surgery in developed countries. A third of the population in
these countries undergoes this procedure. Cataract surgery
is constantly evolving. This is why technological advances
in this area have been ongoing since the introduction of
phacoemulsification in 1960 through to the beginning of
the foldable intraocular lens (IOL) in the late 1980s. As a
result of increased safety and the availability of “premium”
IOLs the spectrum of patients who undergo this procedure
is also changing, with younger patients undergoing lens
removal in order to correct refractive errors and presbyopia.
Femtosecond-assisted cataract surgery promises increased
precision and safety for this procedure.1 These advances
have allowed smaller and smaller incisions,2 from the
incisions of 6.0 to 7.0 mm of extra capsular extraction, to
incisions of 3.4 to 2.8 mm.3 Further reduction in incision
size has been allowed through microincisional cataract
surgery (MICS) that performs incisions less than 1.0 mm.
MICROINCISIONAL CATARACT
SURGERY WITH LESS THAN 1 MM
With the arrival of coaxial MICS, new surgical
techniques appeared, such as biaxial or bimanual MICS,
published for the first time by Shearing et al4 in 1985 and
developed later by Pandey et al.5 The main characteristic
of biaxial MICS is that the cataract surgery is performed
through 2 microcorneal incisions, separately introducing
- 147 -
12
2 instruments in the anterior chamber, a phacoemulsifica-
tion tip and an irrigation handpiece. Therefore, the entire
surgery can be performed through 2 incisions of less than
1 mm and without alteration of anterior chamber stability,
except for the insertion of the IOL that now needs to be
enlarged, but in the near future the incisions will not have
to be enlarged.
Advantages of Biaxial
MICS Versus Coaxial
There are numerous advantages when using smaller
incisions: less invasive surgery,6 the biomechanics7 and
prolate shape of the cornea remain better protected, 8,9
faster healing,9 less inflammation,2,6,10,11 less intraopera-
tive complications,8 less pain for the patient,8 less trauma
to the eye,9 less stress to the tissue,11 improved incision
quality,12 better incision sealing, less risk of fluid out-
flow6,10 and less inflow of fluid and bacteria,6 which carries
a lower risk of endophthalmitis,12 and reduced tendency for
iris prolapse.10 Furthermore, smaller incisions induce less
surgically induced astigmatism (SIA),6,10,12 and particu-
larly provide faster visual rehabilitation (Table 12-1).6,10–12
Besides the advantages of smaller incisions, biaxial MICS
provides additional improvements to cataract surgery,
such as better stabilization of the anterior chamber due
to the separation of the irrigation and aspiration.2,3,10,13
Moreover, because the fluid works as an instrument,10,13
the fluidics are improved3,10,11,13,14 and also the ability
of the pieces of the lens to follow the fluids.8 With less
Buratto L, Brint SF, Sorce R.
Cataract Surgery in Complicated Cases (pp 147-157).
© 2014 SLACK Incorporated.
148  Chapter 12

TABLE 12-1.
ADVANTAGES OF BIAXIAL MICS VERSUS COAXIAL
Effective phacoemulsification time
Phacoemulsification power
Corrected distance visual acuity
Surgically induced astigmatism
Laser flare photometry values
Endothelial cell loss
Central corneal thickness
Complications
BIAXIAL
Less time
Less power
Not statistically significant
Less astigmatism
Not statistically significant
Not statistically significant
Not statistically significant
Not statistically significant
COAXIAL
More time
More power
Not statistically significant
More astigmatism
Not statistically significant
Not statistically significant
Not statistically significant
Not statistically significant

turbulence,3,8,11,14 surgery becomes less invasive,3,8,14 with
less disruption to the surrounding tissues3,8,14 and the cor-
neal endothelium.8
Bimanual MICS allows a reduction in the phacoemul-
sification time2,3,8,10,12,15 and average phaco power,3,12,15
resulting in a shorter effective phaco time and lower ultra-
sound power (Figure 12-1).
The changes induced in keratometry are also lower:
less SIA,2–6,8,10,14 less higher-order aberrations,10,15 and
keratometry readings are comparable to eyes that have
not undergone surgery.16 This is especially important
to patients who will receive “premium” lenses, in whom
the management of astigmatism is necessary in order to
achieve an optimum visual outcome. SIA depends on the
size of the incision, as well as on its location, shape, and
surgical manipulation.1
However, even though the surgeon uses 2 hands, which
increases the efficiency of the phaco, performing certain
maneuvers such as the capsulorrhexis and prechopping
the lens through small incisions becomes a difficult task. It
requires special training for the surgeon, greatly increasing
the learning curve, which can lead some ophthalmologists
to opt for the conventional coaxial technique.
Personal Experience With MICS
We use the Stellaris system and supporting instrumenta-
tion for biaxial MICS (Bausch & Lomb [B&L] [see Figure
12-2]). Stellaris can be used for standard small-incision
coaxial surgery but was designed primarily to optimize
MICS using either a biaxial or a coaxial technique. Burkhard
Dick discussed his preference for a biaxial approach and the
benefits of using the Stellaris Vision Enhancement System.
The technique of biaxial MICS was first described in
1985 by Steven P. Shearing who used it to perform phaco-
emulsification through 2 1-mm incisions.1,4 Thermal injury
to the incision as a result of operating with a bare phaco
needle was a limiting factor that was addressed more than
15 years later through advances in ultrasound power modu-
lation technology that subdivides ultrasound pulses into on
and off phases. Nevertheless, concerns about suboptimal
fluidics have remained as well as limited interest in the
biaxial technique. In particular, these problems relate to the
potential for fluid leakage and collateral fluid loss from the
incision as well as to the limited amount of fluid that can be
aspirated through the thin phaco needle.
Stellaris has successfully addressed these issues. B&L
markets a number of irrigating choppers that all feature a
larger hub lumen to optimize infusion. These instruments
are available in side-opening and end-opening designs,
19- and 20-gauge sizes, and as either reusable or disposable
versions.
StableChamber System, available for use with the
Stellaris platform, further assists in maintaining anterior
chamber stability during biaxial MICS. This tubing fea-
tures an integrated mesh filter to remove nuclear particles
larger than 0.5 mm and is followed downstream by tubing
with a smaller diameter to protect against postocclusion
surge. With StableChamber tubing, surgeons can perform
high vacuum phaco and maintain positive intraocular pres-
sure (IOP) with a deep and stable chamber even on occlu-
sion break.
The Stellaris also has a totally new, 6-crystal handpiece
that is ergonomic, well-balanced, and lightweight. Most
importantly, the handpiece has an increased stroke length
with a tighter curve that allows for more precise and accu-
rate delivery of ultrasound power on demand, and it is also
optimized at 28.5 kHz for rapid emulsification.
MICS Step by Step
Microincision
A well-constructed incision with proper architecture
is a critical factor influencing the success of any cataract
surgery procedure (Figure 12-3).
 Femtocataract Surgery With B-MICS Sub 1 mm  149

Figure 12-1. Bimanual MICS.

Figure 12-3. B-MICS trapezoidal microincision.

MICS, defined as a procedure performed through

incision(s) less than 2.0 mm, should have a negligible
effect on astigmatism and therefore is expected to provide
enhanced visual recovery and a better visual result.17,18
Achieving a successful surgical outcome also depends
on the quality of the incision. A well-constructed incision
enables good instrument manipulation, is important for
maintaining anterior chamber stability, and will be self-
sealing to protect against infection and avoid the need for
suturing that can induce astigmatism.
There are 4 elements to consider in achieving a MICS
incision with quality architecture including location, size,
shape, and self-sealing ability.
1. Location: In my opinion, the incision should be initiated
in clear cornea, not in the limbus, in order to minimize
the risk of chemosis. For bimanual MICS (B-MICS)
procedures, I recommend creating the 2 incisions at
either 2- and 10-o’clock or 3- and 9-o’clock.
2. Size: Regardless of the MICS technique, achieving
the desired incision size at completion of the case
depends on selection of the proper technology, includ-
ing the blade used for incision construction along with
the instruments used for lens removal, the IOL, and
the implantation system. The incision size and phaco
instrument size must be well-matched. After lens
Figure 12-2. Stellaris system.
removal, one incision is enlarged to 1.7 mm to allow
the implantation of the IOL.
3. Shape: Incision shape and its ability to self-seal are
affected by the relationship between the length of
the corneal tunnel and the angle of entry. The angle
of entry should be approximately 45 degrees, as this
approach will create a proper “trapdoor” that self-
seals the incision to provide a natural barrier against
leakage. With a properly oriented angle of entry, the
outward forces of IOP will push on the internal aspect
of the incision and seal it shut; otherwise, IOP will push
aqueous out of the eye. The angle of entry also deter-
mines tunnel length (the greater the angle, the longer
the tunnel) that in turn has effects on surgical access,
instrument maneuverability, intraoperative leakage,
and the ability of the incision to seal. Tunnels that are
too long or too short each have their advantages and
disadvantages. The optimum tunnel length represents
150  Chapter 12
Figure 12-4. Capsulorrhexis with trypan blue staining.
a good balance of these features in terms of providing
good surgical access to the cataract closest to the inci-
sion, allowing instrument maneuverability, minimiz-
ing leakage, and achieving a good seal.
It is important to establish adequate IOP because a firm
anterior chamber allows a proper, clean penetration
of the blade through the corneal tissue that enables
reproducible incision construction. When performing
a B-MICS procedure, surgeons should inject additional
viscoelastic before making the second incision to be
sure the eye is not too soft.
4. Self-sealing: As already mentioned, there are numerous
incision- and surgery-related factors that can affect
the ability of the incision to self-seal. Incision integ-
rity should always be assessed at the completion of the
case by placing a triangular sponge on the external
edge of the microincisions to check for watertightness.
Hydrating the lateral edges with BSS to create corneal
edema will facilitate coaptation of the incision valve
and minimize the risk of leakage.
Viscoelastic Injection
After the incisions are created, viscoelastic injection is
performed to deepen and maintain the anterior chamber.
Viscoelastic injection is performed with a bent cannula,
taking care not to lose the anterior chamber when enter-
ing the eye. A small amount of viscoelastic is injected near
the incision to prevent the chamber from shallowing, then
the cannula is directed toward the chamber angle opposite
the incision, and the injection begins retracting the cannula
as it progresses in filling the anterior chamber.
Capsulorrhexis
To create the capsulorrhexis through a 1-mm micro-
incision, surgeons can choose from among a number of
instruments.
Manual capsulorrhexis is performed by freehand tear-
ing of the capsular bag tissue, trying to create a continuous
circular capsulorrhexis flap that is as circular and as central
Figure 12-5. B-MICS technique with the Stellaris system.
as possible, guided by visual references such as the pupillary
margin. This process makes it almost impossible to suc-
ceed in creating a perfect manual capsulorrhexis and even
more difficult to perform in cases of borderline pupillary
dilation, shallow depth of the anterior chamber, pediatric
or mature cataracts, or weakness in the zonules or fibrous
capsules.19
In eyes with a white cataract and absence of a red reflex,
capsular staining using the vital dye trypan blue is well
recognized as useful to achieve visualization of the capsu-
lorrhexis edge. However, for surgeons who are just begin-
ning to perform MICS, trypan blue staining can also be a
helpful aid toward achieving creation of a regular, round
capsulorrhexis beginning with their first case (Figure 12-4).
Hydrodissection
Separating the attachments between the lens cortex and
capsule by hydrodissection is a crucial step that enables
safe, efficient, and effective removal of the nucleus, epi-
nucleus, and cortex. Considering the safety of a MICS
procedure, there is no need (in my opinion) to maintain
an epinuclear cushion for protecting the capsule during
nuclear disassembly and phacoemulsification. Therefore,
hydrodelineation is not necessary.
When performing hydrodissection, it is important to
establish conditions that will allow the injected fluid wave
to circulate freely and avoid causing damage to the lens
capsule from excessive pressure in the eye. While capsu-
lorrhexis is performed with a firm eye, surgeons should
be sure that the eye is not overinflated prior to beginning
hydrodissection.
I use a Buratto cannula for hydrodissection, which is
slightly curved at the tip to direct the fluid stream down-
ward; meanwhile, this cannula will not cause any tissue
damage on retreatment. The cannula tip is inserted beneath
the anterior capsular rim and fluid injection is initiated
while depressing the opposite side of the incision to induce
some egress of viscoelastic. This egress is very important
to decrease pressure inside the eye and to avoid posterior

Figure 12-6. VES injection before IOL implantation.
capsule rupture. The maneuver can be repeated 2 or 3 times
in different locations.
Then the nucleus is rotated slightly to ensure that
the cortical attachments have been freed from the capsule.
The rotation also allows the surgeon to evaluate the state
of the zonules. Therefore, hydrodissection with nucleus
rotation is a useful diagnostic maneuver for identifying
problems with zonular laxity in addition to being an
important surgical tool.
This step, in my opinion, is the most important when
you use femtosecond laser cataract surgery.
Prechopped Maneuver
This maneuver is particularly useful for MICS, since
the core break requires less energy to emulsify the cataract.
Manipulation is also lower in the eye.
You have to drive the 2 sharps together and pull in the
opposite direction. Then repeat the process elsewhere, until
several fragments are created.
Lens Removal
The nucleus is rapidly emulsified and can be seen to
be rotating into the tip without evidence of lens chatter.
Thanks to the advanced fluidics system of the Stellaris
platform and use of the flow-resistant tubing, the anterior
chamber stability is maintained using this high vacuum
level (Figure 12-5).
For irrigation/aspiration (I/A), any of the available
biaxial, curved, or bent I/A tips can also be used. However,
any tip works well because of the exquisite vacuum control
provided by the Stellaris. Measurement of the incision
using various size gauges after completing lens removal
confirms that my 1.8-mm incision was not stretched during
phacoemulsification.
The exquisite fluidics control achieved with the Stellaris
platform is well-illustrated by a case involving intraocular
floppy iris syndrome. The dual linear footpedal is a valu-
able asset in these cases because it provides gas pedal-like
precise and instantaneous control of flow and followability.
Femtocataract Surgery With B-MICS Sub 1 mm  151
Figure 12-7. An image of 1.8-mm wound-assisted implan-
tation of Akreos MI60 lens.
Whether working near the iris or away from it, I can adjust
flow and vacuum as needed and can operate on these eyes
safely without using any adjunctive modalities to prevent
iris aspiration.
Implanting the Microincision Lens
Providing patients with the full benefits of a MICS
procedure depends on the ability to implant a high-quality
IOL through a sub 2.0-mm incision. The Akreos AO
microincision lens (Akreos MI60, B&L)20 meets this need.
It can be injected through a 1.8-mm incision and delivers
stable quality of vision. The wound-assisted technique
enables IOL implantation through a 1.8-mm incision with-
out stretching or distorting the incision (Figures 12-6 and
12-7).
The capsulorrhexis opening should be 5.5 mm or slightly
larger, but still covering the optic, and, as in any case, in-
the-bag placement should be verified after implantation.
FEMTOSECOND LASER
CATARACT SURGERY
Femtosecond laser technology, which was approved
recently by the FDA for cataract surgery (though it is in
use for corneal lamellar surgery and for flap creation in
LASIK, and adapted for penetrating keratoplasty), solves
many difficulties of MICS since it can precisely perform
the following maneuvers: capsulorrhexis and prechop-
ping or lens fragmentation, as well as highly accurate
and repeatable corneal incisions, which can be assessed
to reduce pre-existing astigmatism and SIA,21 and also
square incisions, whose architecture is much more stable
and stronger than the rectangular-shaped incision.22,23 The
long history of femtosecond laser refractive surgery demon-
strates the safety of the technique in the ocular structures
(Figure 12-8).21,24
152  Chapter 12
Figure 12-8. Femtosecond laser platform graphic user soft
interface.
Figure 12-10. OCT imaging is performed in real time.
Personal Experience With Laser
Refractive Cataract Surgery
We installed our platform Victus-Technolas femtosec-
ond system in Almeria (Spain) last year. This femtosecond
is the latest generation of femtosecond lasers (Technolas
Perfect Vision/B&L). The Victus platform is the first able
to perform cataract, refractive, and therapeutic procedures
using a single system. The versatility of the platform is pre-
pared to provide high accuracy compared to techniques of
cataract surgery literature (Figure 12-9).
The new laser optical system can be adapted to the spe-
cific requirements of each surgical procedure and has the
following components: acoustic-optical modulator, which
enables electronically selecting the operating frequency, to
control and regulate the energy released pulse stability, and
a second focus “Z” that can vary the depth of treatment in
the cornea and lens procedures.
Victus-Technolas works with OCT and facilitates plan-
ning and performing procedures. The imaging is per-
formed in real time during the procedure and designed to
improve surgeon control. It enables image-guided cataract
surgery planning (Figure 12-10).
Technolas uses a suction clip, separate from the patient
interface, designed to fit different corneal geometries, a
precise suction system to minimize suction loss possibil-
ity, an easy pupil alignment procedure and tilt adjustment,
and a docking monitored by intelligent pressure sensor
Figure 12-9. Platform Victus-Technolas femtosecond
system.
Figure 12-11. Docking technology that minimizes the
possibility of eye tilt or distortion.
that controls precise pressure applied on the eye, always
maintaining safety margins recommended for safe surgery.
It features adjustable pressure control according to
treatment. For corneal procedures, flap cutting (regular
docking) with higher pressures prevents any movement,
ensuring accurate control of depth during the procedure.
Capsulotomy and fragmentation of the lens (soft docking),
with lower pressure below 25 mm Hg to provide an uninter-
rupted passage through the laser corneal endothelial avoid
folds and stresses that may result in deviations of the laser
path, generating less homogeneous cutting (like a stamp)
(Figure 12-11).
We avoid femtosecond laser surgery in patients with
small pupils, corneal scarring, too small palpebral fissures,
cataracts with hardness over grade 4, or in patients who
have just been too anxious to proceed.25
My personal learning curve has been relatively easy. Of
the 60 eyes, 5 developed pupillary constriction during or
 Femtocataract Surgery With B-MICS Sub 1 mm  153

after the laser procedure, and I have had 3 anterior capsular

tags at the beginning of the learning curve. I have not had A
any suction breaks.
Pupillary constriction was evident in the early cases.
We eliminated this problem by injecting intracameral
phenylephrine 1.5%, which is well absorbed given the eye
is slightly inflamed immediately after the laser procedure.
The cases of anterior capsular tags required careful man-
agement. I personally use the capsulorrhexis forceps to
pull toward the center from each point on the perimeter
of the circle, instead of the usual movement. This prevents
undesirable breakages. I have had zero incidence of anterior
capsular tear or rupture of the posterior capsule. In short,
with my first 60 eyes, there have been no significant visual
complications.
Some authors presented laser-related capsular block syn-
drome as a complication specific to laser cataract refractive
surgery.26 The hypothesis is that the gas trapped within B
the crystalline lens during photodisruption increased the
intracapsular pressure. Subsequent hydrodissection further
increases the pressure with the resultant posterior capsular
blowout.26 We have not had this complication.
The precision and consistency of the capsulotomies and
corneal incisions have appeared to improve the refractive
results for patients. We have not yet used the laser for inci-
sions. But, as expected, laser-created incisions will be more
consistent, reproducible, and accurately placed compared
with manually placed incisions.
The learning curve is easier for people who have had
similar experience with femtosecond LASIK surgery as I
have. It appears that surgeons with previous experience
with femtosecond lasers were initially more comfortable, Figure 12-12. Victus under the microscope, to fix the suction
as evidenced by fewer complications. They had fewer ring to the patient’s eye.
attempts docking and fewer suction breaks. Good-quality
docking is essential to good surgery. Poor docking can lead
to a cascading series of events with the resultant inadequate to the Victus suction port, and then post the suction
capsulotomy, capsular tags, and secondary anterior capsu- ring in the center of the patient’s eye. Having ensured
lar tear formation. It is important to proceed only in the the correct ring position, activate the vacuum to suc-
presence of good-quality docking. tion by pressing the pedal or by “clicking” on the icon
of “sucking eye” on the Victus screen. Finally, 5 drops
of anesthesia are instilled on the patient’s cornea.
Femtosecond Laser Cataract Surgery
3. Victus stretcher is turned to position beneath the open-
Step by Step ing cone of the laser, in which the interface is adhered
The procedure is performed in the following manner: to the patient’s curve. “Click” on the icon of “sucking
eye” on the Victus screen. Finally, 5 drops of anesthesia
1. Once properly dilated and instructed, the patient is are instilled in the patient’s cornea (Figure 12-12).
positioned on the stretcher Victus, so that the head is as
horizontal as possible and the iris is centered between 4. Slowly raise the stretcher until the interface is aligned
the eyelids. If necessary, you can adjust the headrest. To perfectly with the corneal surface and centered in the
ensure the patient’s position and minimize head move- suction ring. To ensure a correct docking (eye coupling
ment during the procedure, fasten the Velcro strap to the interface), we can check the LED intelligent pres-
around the head. sure sensor (below the screen) and the screen itself with
the system of video camera images and real-time OCT.
2. Here, the stretcher is rotated until it is positioned under
the microscope to fix the suction ring to the patient’s 5. Then, close the suction ring clamp to prevent any
eye. Before attaching the ring, insert the initial device loss of suction and proceed to the delineation of the
ocular structures (pupillary margin, anterior capsule,
154  Chapter 12

Figure 12-13. Capsulotomy performed with the femtosecond

laser (surgical microscope view). B

and posterior capsule). Most importantly, with the

OCT of Victus, we can view the 360-degree plane
of the anterior capsule, to ensure the capsulotomy is
complete and can see the lens in 2 different planes of
0 and 90 degrees, for proper fragmentation even if the
tilt exists.
6. From that moment, the Victus screen tells us that we
can make the treatment through the laser pedal.

Capsulotomy
Laser-performed capsulotomies are significantly
more accurate in size and shape, more precise, more C
reproducible, and stronger than manually created ones
(Figure 12-13).24 The femtosecond laser capsulotomies may
be positioned exactly where the surgeon deems appropriate
(Figure 12-14).22,23
Auffarth27 found that the difference in capsulotomy cen-
tration between a group of femtosecond-laser-performed
capsulorrhexis and a manual group was statistically
significant: 95 ± 37 μm and 160 ± 90 μm deviation
from perfect centration, respectively. In circularity, the
outcomes were 0.97 ± 0.01 in the femtosecond group and
0.93 ± 0.04 in the manual group, 1.0 being a perfect circle.
The intended capsulotomy diameter was 5.50 mm, and
the femtosecond laser group achieved a capsulorrhexis
diameter of 5.50 ± 0.12 mm. These data confirm the accu- D
racy of the femtosecond-performed capsulotomy to be
far higher than that achieved in the manual procedure
(Figures 12-15 to 12-17).
There are many advantages to a uniform, circular
capsulotomy of the desired size and correctly centered:
better development of the lens removal, greater inhibition
of posterior capsular opacification,19 and the precise cap-
sulotomies are especially advantageous when positioning
the IOL. If there is a complete 360-degree, 0.5-mm overlap
of the anterior capsulotomy over the edge of the IOL, and
the lens is contained within the capsular bag near the effec-
tive lens position (ELP), the refractive outcome is greatly Figure 12-14. Image series showing easy removal of the
rhexis.

Figure 12-15. Femtosecond laser versus manual rhexis.
Figure 12-17. The circularity (ε = Ømin/Ømax) following
the femtosecond laser-assisted and manual capsulor-
rhexis procedure.
improved. This is because IOLs are designed based on the
theory that the lens is placed in a particular position, and if
not, the visual outcome may vary significantly. This effect
is even greater for aspheric, multifocal, and accommodat-
ing IOLs.19
Clinical pearls to achieve more than 80% of free floating
capsulotomies:
● After applying eye suction, add 5 drops of BSS/
anesthetic into the suction clip directly onto the eye.
● Begin docking procedure as usual and observe camera
image.
Femtocataract Surgery With B-MICS Sub 1 mm  155
Figure 12-16. The deviation from perfect centration (ΔR)
following the femto-laser assisted and manual procedure.
● When liquid in the suction clip makes contact with
patient interface, ask surgeon to just slowly go up.
● If there are no “air bubbles” visible anymore in the
camera image, have a look at the OCT.
● If cornea is far away from patient interface, keep going
up.
● If cornea is close to patient interface or touching
(a little gap may be accepted), close the suction clip.
● Bring pressure up to green/upper yellow.
● Plan/start procedure as usual.
This “new” docking procedure will reduce pressure on
the cornea and help achieve free floating (in terms of com-
plete cuts or no bridges/tags). It is not always floating up
because the capsule usually sticks to the cortex and seems
to be attached in some areas even though, when it is being
moved, it does not show any bridges/tags.
I personally use the capsulorrhexis forceps to pull
toward the center from each point on the perimeter of the
circle, instead of the usual movement. This prevents unde-
sirable breakages.
Energy in capsulotomy: We increased the energy from
7000 nJ (standard) to 7500. We got a good capsulotomy
with high energy (close to 90% of free-floating capsuloto-
mies) if we did a perfect docking.
Safety distances: We started with a posterior capsule
safety distance of 1000 μm, then we decreased the posterior
safety distance step by step down to 700 μm (CE approval).
Arcuate Incisions
Femtosecond laser-assisted astigmatic keratotomy allows
the surgeon to correct corneal astigmatism while perform-
ing cataract surgery with a high degree of reproducibility
and accuracy as compared to manual techniques. As we
prefer toric IOLs, we do not make corneal incisions.
156  Chapter 12
Figure 12-18. Lens fragmentation options.
Figure 12-19. Femtosecond laser procedure: capsulotomy +
lens fragmentation. Visible: cuts plus gas dissection of nucleus
and cortex.
Nucleus Treatment
As for the prechopped maneuver, the femtosecond laser
can perform lens fragmentation for cataracts up to grades
3 to 5 and liquefaction28 up to cataract grade 2 (Figure 12-18).
In the same manner as the capsulotomy and incisions,
the surgeon may preoperatively program, in a simple and
effective manner, different fragmentation patterns that
allow fragmentation of cataracts depending on the type and
hardness of the cataract. In our experience, we preferred
6 radial cuts (Figure 12-19).
Energy in lens fragmentation: We increased the energy
from 7000 nJ (standard) to 7500, then 8000. With 8000 nJ,
we saw a better cutting of the lens without risk for the
patient (Figure 12-20).
Figure 12-20. Circular and quadrant lens fragmentation
patterns.
Fragmentation pattern: We started doing 6 radial
cuts smaller than capsulotomy (4500 mm). Now we have
enlarged the size of radial cuts from 6800 to 7000 mm
and we have improved the performance of fragmentation
(Figure 12-21).
RECOMMENDATIONS
In summary, in comparison to conventional phaco-
emulsification, performing cataract surgery with a fem-
tosecond laser enables a better-quality incision, a more
uniform and centered capsulorrhexis,19 and a reduction in
phacoemulsification energy and time,21 thus increasing the
accuracy and safety of the outcomes. These results, and the
benefits of biaxial MICS,18 make combined biaxial MICS–
femtosecond laser a safer and more precise cataract surgery
technique, giving excellent refractive results.
Keeping in mind the quality and requirement levels of
current cataract surgery, biaxial MICS is the safest and

Figure 12-21. Easy cracking of nucleus following lens
fragmentation.
most accurate technique available, and, coupled with fem-
tosecond laser technology, which significantly enhances
the capsulotomy and lens fragmentation maneuvers, has
become the technique that provides the best outcomes in
cataract surgery.
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1. Álvarez-Rementeria L. Surgical induced astigmatism in femtosec-
ond laser assisted cataract surgery. J Emmetropia. 2012;3:61-65.
2. Kurz S. Biaxial microincision versus coaxial small-incision clear
cornea cataract surgery. Ophthalmology. 2006;113:1818-1826.
3. Yu J. Biaxial microincision cataract surgery versus conventional
coaxial cataract surgery: metaanalysis of randomized controlled
trials. J Cataract Refract Surg. 2012;38:894-901.
4. Shearing SP, Relyea RL, Louiza A, Shearing RL. Routine phaco-
emulsification through a one-millimeter non-sutured incision.
Cataract. 1985;2(2):6-11.
5. Pandey SK, Werner L, Agarwal A. No anesthesia cataract sur-
gery. In: Agarwal S, Agarwal A, Sachdev MS, Mehta KR, Fine
IH, Agarwal A, eds. Phacoemulsification, Laser Cataract Surgery
and Foldable IOLs. 2nd ed. New Delhi, India: Jaypee Brothers;
2000:217-225.
6. Allen D. Final incision size after implantation of a hydropho-
bic acrylic aspheric intraocular lens: new motorized injector
versus standard manual injector. J Cataract Refract Surg. 2012;
38:249-255.
7. Alió J. Factors influencing corneal biomechanical changes after
microincision cataract surgery and standard coaxial phacoemul-
sification J Cataract Refract Surg. 2010;36:890-897.
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8. Can I. Coaxial, microcoaxial, and biaxial microincision cataract
surgery: prospective comparative study. J Cataract Refract Surg.
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9. Elkady B. Corneal incision quality: microincision cataract sur-
gery versus microcoaxial phacoemulsification. J Cataract Refract
Surg. 2009;35:466-474.
10. Moore S. Intraoperative floppy-iris syndrome and microincision
cataract surgery. J Cataract Refract Surg. 2010;36.
11. Crema A. Comparative study of coaxial phacoemulsification and
microincision cataract surgery; one-year follow-up. J Cataract
Refract Surg. 2007;33:1014-1018.
12. Cleary G. Randomized intraindividual comparison of posterior
capsule opacification between a microincision intraocular lens
and a conventional intraocular lens. J Cataract Refract Surg.
2009;35:265-272.
13. Alió J. Outcomes of microincision cataract surgery versus coaxial
phacoemulsification. Ophthalmology. 2005;112:1997-2003.
14. Can I. Aspheric microincision intraocular lens implantation with
biaxial microincision cataract surgery: efficacy and reliability.
J Cataract Refract Surg. 2010;36:1905-1911.
15. Kurz S. Biaxial microincision versus coaxial small-incision cat-
aract surgery in complicated cases. J Cataract Refract Surg.
2010;36:66-72.
16. Kaufmann C. Astigmatic neutrality in biaxial microincision cata-
ract surgery. J Cataract Refract Surg. 2009;35:1555-1562.
17. Fine I. Optimizing refractive lens exchange with bimanual
microincision phacoemulsification. J Cataract Refract Surg.
2004;30:550-554.
18. Haustermans A. The StableChamber system: Breaking the link
19.
between vacuum and aspiration flow. Free Paper, ESCRS 2006.
Friedman N. Femtosecond laser capsulotomy. J Cataract Refract
Surg. 2011;37:1189-1198.
20. Brooks L. 1.8 mm Biaxial MICS. White Paper: A review of the
literature European publication, July 2007.
21. Hodge C. Femtosecond cataract surgery: a review of current
literature and the experience from an initial installation. Saudi
Journal of Ophthalmology. 2012;26:73-78.
22. Bali S. Early experience with the femtosecond laser for cataract
surgery. Ophthalmology. 2012;119:891-899.
23. Dick H. Femtosecond laser in ophthalmology—a short overview
of current applications. Medical Laser Application. 2010;25:
258-261.
24. Alió J. Cataract surgery with femtosecond lasers. Saudi Journal of
Ophthalmology. 2011;25:219-223.
25. Packer M. LENSAR laser system applications in refractive cata-
ract surgery. S Cataract Refract Surg Today. 2012(May):3-6.
26. Lawless, MD. Femtosecond laser cataract surgery: an experience
from Australia. Asia Pacific J Ophtalmol. 2012;11:5-10.
27. Auffarth G. Preliminary clinical results of the femto-cataract pro-
cedure using the VICTUS™ Femtosecond Laser Platform. White
Paper, September 2011.
28. Nagy Z. Advanced technology IOLs in cataract surgery: pearls
for successful femtosecond cataract surgery. Int Ophthalmol Clin.
2012;52(2):103-114.

Laser-Assisted Cataract Surgery
With the LenSx Femtolaser
Lucio Buratto, MD and Stephen F. Brint, MD, FACS
Routine cataract surgery has now become refractive
surgery—patients have grown to expect emmetropia and
to be primarily spectacle independent! And if that were not
enough, they rightly expect good quality of vision, so there
is increased pressure on eye surgeons to provide high-quali-
ty vision. The main objective of surgery is still to restore the
best visual acuity possible considering the conditions of the
eye, but there are also increased expectations of good vision
without detectable aberrations.
To achieve this aim, what is required is the most “accu-
rate” surgery possible, reducing or correcting preexisting
refractive errors, preventing the induction of astigmatism,
preserving the ability to focus at near in many cases, and, in
general, ensuring high-quality vision, avoiding alterations
or damage to the cornea, retina, and vitreous.
Femtosecond laser surgery is precise, safe, reliable,
accurate, and reproducible. These features can improve the
surgical outcome, making this a bright future for cataract
surgery.
The term femtosecond comes from the duration of each
laser impulse, which lasts only a tiny fraction of a second.
The diameter of each laser spot is less than 2 μm and the
light’s wavelength is in the infrared spectrum (1053 nm).
In theory, the laser beam (IR wavelength) can be focused
on any intraocular tissue with the energy raised to a thresh-
old that causes what is called optical breakdown at the
focal point. The high energy released in a very short time
interval creates plasma, which is followed by cavitation
bubbles and a wave. To cut or separate tissues, the distance
between one spot and the next must be appropriate, the
- 159 -
13
separation between one spot and the next must be short,
and the energy must be released in precise patterns that can
be programmed by the operating surgeon. Considering the
diameters involved, numerous laser emissions are required.
After paying homage to the pioneering work of Kelman,
the father of phacoemulsification (which over 100 million
people in the world benefitted from), a second revolu-
tion is starting in the field of cataract surgery: the age of
femtolaser.
The energy provided by this laser has, for many years,
allowed refractive surgeons to create corneal incisions and
flaps with accuracy, precision, and reproducibility, using
robotic tools for most of the surgery and keeping side
effects to a minimum. Cataract surgeons expect this laser
to provide the same level of precise cutting in many steps of
the cataract procedure.
To date, innovation and evolution of cataract surgery
have included improving technology of phacoemulsifica-
tion systems (with the aim of improving fluidics and reduc-
ing trauma to eye tissue), the design, materials and types
of intraocular lenses (IOLs), to allow patients to see at all
distances with minimal visual aberrations, the viscoelastic
substances that make them more suitable to satisfy all the
needs of surgeons; yet until now no one thought of remov-
ing the last variable—the human factor, linked to surgeon
skill and experience, which are subjective factors.
The femtosecond laser has marked the beginning of a
new age, in which cataract surgery is approached differently
with the first part of the surgery performed by the laser
which can be programmed and executed without blades, in
Buratto L, Brint SF, Sorce R.
Cataract Surgery With Phaco and Femtophaco Techniques (pp 159-174).
© 2014 SLACK Incorporated.
160  Chapter 13
Figure 13-1. (A, B) The laser beam performs the capsulotomy; the procedure is started below the anterior and completed above:
this is the first phase of laser treatment.
an extraordinarily precise and reproducible manner. This
device creates the following:
● Clear corneal incisions
● Corneal relaxing incisions for the correction of astig-
matism (if necessary)
● Anterior capsulotomy
● Nuclear fragmentation
All these procedures are computer programmed and
are reproducible every time using a laser having the same
characteristics.
CAPSULOTOMY
Capsulotomy is often a challenging procedure for inex-
perienced surgeons and can be difficult for experienced
surgeons as well. With the femtosecond laser, a few seconds
are all it takes to perform a perfectly circular capsulotomy
of the desired size at the desired site (capsulotomies of dif-
ferent shapes can also be performed by programming the
laser). These aspects are currently important for the inser-
tion of premium IOLs whose performance depends, in part,
on the shape and site of the anterior capsulotomy, in order
to avoid decentration caused by asymmetric vector forces or
contraction of the capsular bag because of irregular shape
(Figures 13-1).
NUCLEAR FRAGMENTATION
The fragmentation pattern must be set by the surgeon
according to the degree of nuclear density and surgical
preferences. The femtolaser’s software can be programmed
to make linear and/or circular cuts in the crystalline lens,
similar to the latitude and longitude lines on a globe. In
the second OR portion, the lens material can be removed
with a phacoemulsification device using only vacuum (if
the nucleus is soft) or very low amounts of energy (if the
nucleus is moderately hard). Ultrasound-induced trauma
on the eye tissue (zonules in particular) and endothelial cell
loss are minimized.
Pretreating the nucleus with laser makes the removal
of cataracts (even dense ones) easier and quicker (with
reduced trauma) because the precise, linear cuts allow
cleavage planes to propagate inside the crystalline lens,
whereas circular ablations cut the central core of the nucle-
us, making it softer and easier to remove. Femtolasers allow
surgeons to use reduced ultrasound energy for all nuclei
and, most importantly, limit the amount of energy required
for dense ones. Another consequence is the reduced use
of balanced salt solution (BSS).
Simply stated in 2 words: effectiveness and safety
(Figures 13-2 to 13-4).
 Laser-Assisted Cataract Surgery With the LenSx Femtolaser  161
Figure 13-2. Laser emission inside the nucleus to divide it into
4 quadrants. This is the laser phase after capsulotomy.
Figure 13-4. In addition to straight incisions, the laser can make
circular nuclear incisions of various diameters.
CORNEAL INCISIONS
Corneal incisions (corneal tunnel and paracentesis)
are performed with great accuracy by programming the
desired incisional architecture. The site of incision is
chosen according to preoperative topographic values and
surgeon preference and intraoperative pachymetry values
provided by the optical coherent tomography (OCT). The
surgeon chooses the shape and size of the tunnel, with 2 or
Figure 13-3. Laser emission takes place starting from the deep
layers and moving toward the surface ones.
3 planes, with different inclination, depth, width, shape,
and length. The surgeon also chooses the site—temporal,
superior, or elsewhere—with the aid of the integrated OCT.
The corneal tunnel—a multiplanar incision on 2 or 3 lev-
els—during and after the surgery has excellent flap apposi-
tion and is easy to close. This is associated with a lower risk
of complications (such as loss of fluid from the wound and
the entry of external secretions into the anterior chamber),
which should reduce the risk of endophthalmitis.
Various parameters of paracentesis (1 or 2) can be pro-
grammed, such as shape, distance from the main incision,
size (width and length), and, naturally, the site(s).
When performing corneal relaxing incisions, moderate
astigmatic errors can be corrected by using the laser to per-
form keratotomy procedures in exactly the desired location,
of exactly the desired depth, and angle length, which can-
not be achieved in keratotomies performed manually with
steel or diamond knives.
The unique and special feature of relaxing incisions per-
formed with laser technology is that surgeons can tailor the
procedure to each patient, performing different treatment
patterns based on the diameter of the optic zone, the length
and depth of the incision, and the incision angle, depending
on the amount of astigmatism, corneal thickness, age, and
pupil diameter. It is therefore easier to perform incisions
that are exactly on the axis of astigmatism and are perfectly
symmetrical (in the case of symmetrical astigmatism or, if
this is not the case, asymmetrical), as well as being the same
distance from the pupil. This result is difficult to achieve
with manual incisions.
Another important unique feature of femtosecond laser
keratotomy is that incisions may be just intrastromal, that
162  Chapter 13
Figure 13-5. Execution of the main incision in the procedure
with femtolaser.
Figure 13-7. Execution of the second secondary incision. This is
the last phase of the femtolaser treatment.
is, without cuts in the epithelium and Bowman membrane.
This spares the patient the symptoms typically associ-
ated with corneal wounds and allows the surgeon to decide
whether the incisions need to be opened or not (to increase
the reduction of astigmatism) after surgery (Figures 13-5
to 13-7).
Figure 13-6. Execution of the first secondary incision in the
procedure with femtolaser.
THE LASERS
A number of laser platforms, with differing features,
are currently commercially available. Four companies have
developed the femtosecond lasers listed below:
1. LenSx Laser Inc (Alcon) (Table 13-1)
2. LensAR Inc (Topcon)
3. OptiMedica Corporation
4. TPV Technolas
LenSx and Catalys (OptiMedica) use 3D OCT to guide
the laser in the eye and to create corneal incisions with a
self-sealing, interlocking configuration, similar to that used
for penetrating keratoplasty.
LenSx uses a rigid, curvilinear patient interface (PI) to
adjust to the cornea’s curvature. By late 2012, a new PI was
released using a disposable soft contact lens, which provides
improved docking, improved quality of the capsulotomy,
and minimal increase in IOP. Catalys uses a liquid interface
that provides the best contact with the eye without requir-
ing a significant increase in ocular pressure.
LensAR, originally designed to correct presbyopia, uses
a Scheimpflug camera-based biometric system and devel-
ops a cubic pattern of laser impulses that divide the crystal-
line lens into small, die-shaped parts.
Victus (TECHNOLAS, A Bausch + Lomb Company) has
a simple docking technique and the instrument is guided by
 Laser-Assisted Cataract Surgery With the LenSx Femtolaser  163

TABLE 13-1.
BURATTO S LENSX PARAMETERS
Procedure Energy (µJ) Distance between Distance between spot
individual spots (µm) lines (µm)
Capsulotomy 6.0 4 3
Chop 7.0 12 10
Cylinders 7.0 12 10
Arcuate incisions 6.0 4 4
Main and secondary incisions 6.0 6 4

Figure 13-8. The OCT makes it possible to display the Figure 13-9. The OCT displays the lens and the surgeon
anterior chamber and program the upper and lower laser can program the depth and extension of the laser incisions
emission levels of the anterior capsule. within the nucleus.

Optical Coherence Tomography

Figure 13-10. The OCT displays the cornea and the opera-
tor can program the depth and extension of the various
laser incisions.
real-time OCT during the entire laser procedure, ensuring
accurate measurement of intraocular elements (the crystal-
line lens in particular), as well as providing an excellent
image of the anterior and posterior capsule of the crystal-
line lens. Surgeons who wish to perform keratotomy pro-
cedures using Victus must perform a second docking with
a different PI than that used for the laser fragmentation of
the crystalline lens.
The lasers have a high-resolution OCT system.
This method—first developed for ophthalmology—has
been used in diagnostics of the anterior and posterior seg-
ments of the eye for a number of years, but this is the first
time it has been used on a “surgical” instrument.
OCT is a noninvasive imaging technique that yields
excellent results in medical imaging and in measuring the
components of the human eye. OCT images are acquired
by transmitting energy waves into the tissue and measuring
the echo of the reflected waves. The “streaked” appearance
of images of homogeneous tissue such as the cornea is an
effect of the granularity caused by the coherent light used
in OCT.
OCT generates transverse images of the components
of the eye and provides a direct, high-resolution image,
without contact with the eye, making this a noninvasive
technique. The axial resolution of the image is 10 μm at
a 1310-nm wavelength. The size of the acquisition slice is
about 10 mm.
OCT imaging does not just provide a qualitative assess-
ment of the various eye tissues—it can supply quantitative
information, since it can be used to measure the thick-
ness, diameter, and anomalies of the eye profile and the
164  Chapter 13
Figure 13-11. The video microscope makes it possible to dis-
play the cornea and program the site of the main incision and
secondary ones.
homogeneity of tissue. This is useful in the OCT devices
used in femtosecond lasers (Figures 13-8 to 13-11).
Femtolaser Surgery
There are 2 distinct components:
1. Laser component, with predocking programming, the
application of the suction ring, docking, OCT, post-
programming of the laser treatment, and the execution
of the laser phase.
2. Surgical component, in which the surgeon opens one
of the incisions, injects viscoelastic substance (VES),
removes the capsule, opens the second and third
incision (if done), performs careful hydrodissection,
removes the nucleus, then removes the cortex, and
implants the IOL.
Laser Phase
Predocking Programming
Before starting the laser procedure on a patient, the
surgeon must program what is desired from the laser, for
example, the position, shape, width, architecture, and
length of the primary incision and the accessory incision(s).
The size of the capsulotomy must be programmed.
A pattern must be chosen for nuclear fragmentation (this
depends on the density of the nucleus and other param-
eters). The surgeon must choose a cylindrical, linear, or
mixed pattern and appropriate dimensions. The energy of
each individual spot, the distance between one shot and the
next, the emission frequency, and the succession must be
established before patient treatment with any of the proce-
dures above. This typically remains fixed.
Laser Treatment of the Patient
The surgeon must apply a few drops of topical anesthetic,
insert an adjustable lid speculum and adjust it to obtain a
wide palpebral aperture. The patient’s head should be on a
firm cushion on the stretcher and parallel with the floor,
allowing maximal and equal conjunctival exposure. The
suction ring is applied so that the integrated OCT device
may take accurate measurements and after subsequent pro-
gramming, direct the laser to the correct depth and place-
ment. Additionally, it prevents eye movement during laser
emission, obviously undesirable.
The next step in the procedure is docking, that is, bring-
ing the laser device in contact with the eye.
Docking consists of allowing the cornea and the sur-
rounding conjunctiva to adhere to a special plastic “cone”
called the PI with suction. The PI must allow the OCT
device in the instrument to scan the anterior segment, that
is, measure the thickness and the distance between the vari-
ous eye structures involved in cataract surgery.
Good docking requires that the applanation is paral-
lel to the anterior and posterior surface of the crystalline
lens, so that the laser treatment is performed on planes
that are parallel to the structures it needs to interact with
(Figure 13-12).
Using the joystick, the surgeon (or the laser technician)
moves the tip of the laser until the PI enters the suction ring
and is in contact with the eye. While moving the laser closer
to the eye, the surgeon must instruct the patient to fixate
into the laser correctly and continuously in order to center
it most effectively. An optimal connection between the eye
and the PI is very important—other than allowing the OCT
device to take accurate measurements, it also leads to faster
programming of the laser procedure.
The docking step is the most important part of the
laser procedure because if it is performed incorrectly, the
measurements taken by the OCT device may be inaccu-
rate, which means that the surgical program may also be
inaccurate. It is therefore very important to obtain a stable
connection between the eye and the PI and for the PI to be
aligned with the laser’s optical system. If the laser’s optical
system is not aligned (if even by the fraction of a millime-
ter), at least part of the energy will be directed incorrectly,
achieving less accurate results and performance or causing
complications. If, for example, the applanation made by
the PI is not perfectly parallel to the anterior surface of
the crystalline lens, the capsulotomy may be incomplete or
not perfectly executed. The nucleus may not be sufficiently
divided and/or divided into wrong planes (which, extreme-
ly rarely, can cause the posterior capsule to break). The
corneal incisions may be incorrect, that is, too anterior or
posterior; they could be incomplete or of a different shape
from the one desired in the program.
 Laser-Assisted Cataract Surgery With the LenSx Femtolaser  165
Figure 13-12. PI is a cone placed in contact with the eye through
a special contact lens in order to create a close relationship
between the eye and laser; this lets the OCT make accurate
measurements.
Incorrect docking may also lead to loss of suction during
surgery, which terminates the laser procedure and does not
allow the surgeon to have the advantages offered by laser
treatment. The possible loss of suction during the laser pro-
cedure must be immediately noticed. A meniscus or redun-
dant conjunctival tissues appearing on the monitor’s screen
are clues that can warn about an imminent loss of suction.
In these conditions, intraocular procedures can continue
in most cases, whereas corneal incision procedures must
almost always be stopped and finished surgically. Tight
palpebral fissures, pediatric age, and flat corneas have been
identified as risk factors in loss of suction. The incidence
of loss of suction during LASIK femtosecond laser surgery
has been reported to be 0.06% to 0.27%.1 There is currently
no statistical data on the use of femtosecond laser for cata-
ract surgery, but loss of suction is a complication that may
occur. Good docking can be achieved by making sure the
patient is in the correct position, avoiding interference from
the nose and talking to the patient through the procedure,
ensuring he or she looks into the laser. A stable bed with
elevation that can be adjusted by the surgeon (to obtain the
best bed–patient–laser condition) is also useful.
All the previously mentioned is not, by itself, enough. An
adequate palpebral opening, a distended conjunctiva with-
out significant abnormalities, a conjunctival sac free from
liquid, and cooperation from the patient are required—
partly because the docking procedure can be uncomfortable
and, on the whole, lasts 2 to 3 minutes. Once docking has
been performed correctly, the surgeon (or the laser techni-
cian) uses the computer keyboard or mouse to program the
various treatment steps, one at a time. To begin with, he or
she must check that the OCT device is centered on the eye,
then check that the programmed capsulotomy is perfectly
centered or slightly decentered as desired on the pupil.
Next, he or she must check the OCT projection of the crys-
talline lens and establish at what depth the laser emission
must start and end (usually 500 to 600 μm from the poste-
rior and the anterior capsule) and therefore the crystalline
Figure 13-13. The laser phase is an unsterile part of the opera-
tion; the surgeon gives the laser technician instructions useful
for correct programming based on the clinical situation.
lens cut. The ablation pattern is selected prior to docking.
Next, the surgeon (or the laser technician) must examine
the anterior capsule and ensure it is on a horizontal plane,
as this is important to achieve a complete (360 degrees) cap-
sulotomy. To be on the safe side, the operator must program
the computer so that the laser treatment begins under the
capsule and ends above it. In this way, the capsule is certain
to be cut all the way through (Figure 13-13).
To perform the capsulotomy, laser emission is started
300 to 400 μm under the capsule (delta down), in the super-
ficial material of the crystalline lens, and gradually moves
upward in a spiral motion (delta up) until it reaches the cap-
sule. It moves into the anterior chamber for 300 μm—this
is very important because the capsule thickness may vary
in different areas. Furthermore, the crystalline lens (and
therefore the capsule) may not be on a perfectly horizontal
plane (the crystalline lens may be tilted due to imperfect
docking) and in this way allows the laser emission to com-
pensate for small abnormalities caused by less-than-perfect
docking. Naturally, in the post-docking programming
phase, the surgeon has centered the capsulotomy site as
well as possible, whereas the diameter and shape are pro-
grammed in the pre-docking phases. Occasionally, despite
accurate docking and precise programming, the capsule is
not cut 360 degrees, which may depend on other reasons
(described next).
Once the laser surgery is fully programmed, the surgeon
presses the pedal that activates the laser and the proper
surgery begins. It usually takes 40 to 50 seconds of laser
time. The first step is capsulotomy (FECA—FEmtolaser
CApsulotomy or CApsulotomy with FEmtolaser CAFÉ),
which is not actually a capsulorrhexis but a “micro can-
opener.” It is not a continuous opening (like a tear-open
lid) but a series of micropunctures or capsular perforations
instead. They are very close to each other and the final result
is an extremely precise and perfectly circular (and resistant)
capsulotomy. Once the capsulotomy is complete, the laser
program continues with the programmed procedure in the
166  Chapter 13
Figure 13-14. Once the laser phase is completed, the patient is
moved under the operating microscope; the surgeon first uses
a blunt spatula to open the various incisions, then injects visco-
elastic and next removes the anterior capsule cut by the laser.
nucleus. If programmed, corneal relaxing incisions for the
correction of astigmatism are performed next, followed by
the creation of the main and accessory incisions. The laser
procedure is then finished.
SURGERY PHASE
The patient is moved under the operating microscope
and surgery is performed.
The surgeon should use the best magnification and light
of the microscope to check if the capsulotomy is complete—
the surgical procedure is different if there are microconnec-
tions or extensive areas of uncut capsule.
Opening the Incisions
To begin with, using a blunt spatula, the surgeon opens
one of the accessory incisions and immediately injects a
VES (possibly viscoadaptive, such as Discovisc [Alcon]),
in order to avoid shallowing or flattening of the anterior
chamber and, possibly, the rupture of the anterior capsule,
should there be a point of lower resistance.
Next, the other accessory incision may be opened (if cre-
ated), then the main incision.
Blunt spatulas are used to open the incisions because the
opening procedure is actually a dissection of the tissue on
which the laser has worked, similar to the creation of a flap
in the LASIK procedure. It should be noted that the eye is
considered closed until the surgeon opens the incisions
with the spatula. This means the laser procedure can be
performed in a different operating room or even building
that is not where surgery is performed. Some time may
lapse between the laser procedure and the surgery, even if
it is preferable for surgery to follow immediately, in order
to avoid pupil constriction due to the release of energy in
the eye.
Removal of the Anterior Capsule
At this point, the anterior capsule may be removed. It
is essential that the surgeon confirms that the capsule has
been completely cut (360 degrees) or if micro- or mac-
roscopic connections have remained. This information
is crucial in determining how to proceed. The anterior
capsule is not always visible because the anterior chamber
is often turbid (trypan blue can be very useful in this situ-
ation). Turbidity is essentially caused by 2 factors. The first
factor is the stirring up of cortical material just under the
anterior capsule caused by the laser beginning the ablation
procedure about 300 μm under the capsule. This reduces
the red reflex and, in any case, may not allow the capsule to
be viewed clearly. The second factor is the presence of gas in
the nucleus and, in general, under the anterior capsule. The
gas is a result of the ablation—the tissue disintegrated by
the laser is transformed into gas (plasma) that is trapped in
the crystalline lens material and may hinder visualization
of the red reflex (and therefore visibility for the surgeon).
This occurs mainly in the observation/removal of the ante-
rior capsule as well as during hydrodissection. The surgeon
proceeds differently depending on whether the capsule is
perfectly cut (360 degrees) or tissue connections remain.
1. If the capsule is completely cut (360 degrees), the sur-
geon can choose between removing the cleaved capsule
with forceps and using the aspiration function of the
U/S tip (Figure 13-14).
a. Assuming the surgeon removes the capsule with
forceps, he or she can follow the traditional phaco-
emulsification procedure to perform hydrodissec-
tion. If this is done, it must be performed cautiously,
because the capsular bag contains bubbles, which
increases its tension and makes it more likely to
rupture. Before carrying out hydrodissection, the
surgeon may decide to use phacoemulsification to
remove the superficial layer of lens material in order
to obtain better results, aiming at achieving the
3 objectives listed next:
i. To remove part of the anterior cortical material
that came loose during the laser emission and
during the removal of the anterior capsule. This
step improves visibility in the anterior segment
and especially of the contents of the capsular bag.
ii. To decompress the capsular bag because, by
removing some of the lens material, part of the
 Laser-Assisted Cataract Surgery With the LenSx Femtolaser  167
Figure 13-15. Next, a hydrodissection is performed carefully.
gas that formed in the nucleus can be released
and enter the anterior chamber, improving vis-
ibility of the nucleus and better see the progres-
sion of the hydrodissection BSS wave (that will
take place later).
iii. To clearly visualize the linear cuts made by the
laser (if this was the chosen pattern) and decide
to divide the nucleus into 2 parts with a prechop-
per, to make the next steps of the procedure
easier and to release more plasma bubbles from
the lens material.
Having done this, visibility in the anterior seg-
ment has improved and the red reflex is better.
b. The surgeon can decide to remove the anterior cap-
sule using the aspiration of the U/S tip and continue
with the phacoaspiration or phacofragmentation of
the nucleus. However, the surgeon must be quite
sure that the nucleus is soft enough to be easily aspi-
rated even without hydrodissection. Alternatively,
the surgeon must have good bimanual dexterity and
be able to perform hydrodissection with the non-
dominant hand and use the phaco handpiece with
the dominant hand.
2. Incomplete capsulotomy: The surgeon must complete
the capsulotomy using capsulorrhexis forceps. Great
caution is required in this step in order to avoid a resid-
ual tissue connection transforming into capsulorrhexis
escape. This is the most challenging and difficult step
the surgeon has to manage after initial treatment
with the femtosecond laser for cataract surgery. Poor
visibility of the capsule and the presence of a plasma
Figure 13-16. The surgeon then completes splitting of the
nucleus into 4 quadrants, using a prechopper.
bubble-filled capsular bag can make completing the
capsulotomy very difficult. The use of trypan blue and
injection of an appropriate viscoadaptive substance
(Discovisc) can greatly help the surgeon. After remov-
ing the anterior capsule (and eventually some of the
anterior lens material), the surgeon may elect to pro-
ceed with careful hydrodissection, carefully observing
the progression of the BSS wave that separates the pos-
terior capsule from the posterior epinuclear material.
Hydrodissection
This step must be performed with caution and without
injecting too much BSS in the capsular bag, which may
already be expanded by the presence of the bubbles. At the
end of hydrodissection, rotation of the nucleus in the cap-
sular bag (to be certain, it is not connected to the bag any
more) should be performed (Figures 13-15 and 13-16).
Phaco
At this point phaco may begin. The technique to be used
depends on the density of the nucleus and, in the case of
femtolaser-treated nuclei, on the nuclear dissection pattern
used. However, it is important to bear in mind that the cuts
in the crystalline lens material are not complete and the
deeper layer remains uncut. The surgeon must be able to
deal with a nucleus that is divided only centrally and has a
“posterior bowl” that is not cut because of its proximity to
the posterior capsule. In this case—especially if the nucleus
is soft or not very dense—it is advisable to proceed with
flipping the epinucleus after removing the inner, harder
nucleus. Usually, if the nucleus is of the appropriate consis-
tency, a prechopper can be used to divide the nucleus and
168  Chapter 13
Figure 13-17. The quadrants are then removed using a
phacoemulsifier.
the deeper layer that has not been cut by the laser, or this
may be accomplished using the phaco tip and the second
instrument, spatula or chopper.
Most femtosurgeons prefer to use a laser with a cylin-
drical pattern on nuclei considered soft or not very hard
before surgery. The cylindrical pattern has the advantage of
further softening an already soft nucleus, which can then
be removed simply using the irrigation/aspiration (I/A)
handpiece or the U/S handpiece without ultrasound. To cut
hard nuclei, femto-surgeons mostly use a laser pattern that
divides the nucleus into 2, 4, 6, or 8 parts. Surgeons must be
aware that laser ablation does not “cut” and that tissue con-
nections remain. A chopper is therefore required to sepa-
rate the sectors completely. Alternatively, a prechopper can
be used before phacoemulsification. The nucleus division
pattern can also be mixed, that is, there may be 1 or more
cylinders combined with 1 or more linear divisions. When
dealing with hard or semi-hard nuclei, it is very useful to
perform a 3-mm cylindrical cut and 2 linear cross incisions,
which allow the surgeon to remove the 4 central parts of the
nucleus first. After dividing the nucleus into 4 parts with
a prechopper or a chopper, the 4 sections can be removed
very easily using the “quadrant removal” parameters of
Infiniti (Alcon) with the Ozil system. If the nucleus is cut
into 4 or 6 sectors, the anterior epinucleus must be removed
first. The surgeon may then use a chopper to fully divide
the sectors and remove them using a standard technique
(Figure 13-17).
Irrigation/Aspiration
After phaco, the cortex must be removed. Many femto-
surgeons have noted that more cortex remains and it is
more adherent to the anterior and posterior capsule. This
is probably secondary to the more cautious hydrodissec-
tion performed after femtofragmentation of the nucleus, as
well as the fact that the anterior cortical material is cleanly
cut during the capsulotomy, without the tags typically left
after manual capsulorrhexis. It could also be caused by
the gas bubbles released in the capsular bag that make the
cortex adhere to the capsule more strongly. The cortex can
be removed with the I/A coaxial tip or with the Buratto
bimanual technique. In femtolaser surgery, the latter pro-
cedure has many advantages, as it allows the chamber to be
deep during the entire procedure and, most importantly,
to access every part of the capsular bag without inducing
excessive pressure or traction on the incisions.
New Instruments
Using a femtosecond laser leads to changes in surgery
technique and, therefore, to the use of new instruments. A
small, flat spatula with a blunt tip is required to open the
corneal incisions. A prechopper with a new design is needed
to fully divide the nucleus after laser phacofragmentation.
Special forceps—suitable for gripping the anterior capsule
and detaching residual capsular connections—is necessary.
CONTRAINDICATIONS TO
FEMTOLASER SURGERY
Possible indications and contraindications to the opera-
tion are essentially associated with the following factors:
1. Characteristics of the conjunctiva
2. Exposure of the eye
3. General conditions such as patient cooperation/anxiety
4. Transparency of the cornea
5. Diameter of the pupil
6. Depth of the anterior chamber
Conjunctiva: Anything that hinders correct docking is
a contraindication to laser treatment. A postglaucoma sur-
gery bleb, conjunctival or palpebral pathologies that limit
palpebral opening, and even loose conjunctiva can make
correct docking impossible, which means no laser surgery
can be performed. It is important to bear in mind that there
are considerable differences between docking for LASIK
and docking for cataract surgery. The former only needs
contact with the cornea, includes the ablation of the super-
ficial layers of the cornea, is performed quickly, requires xy
energy, raises intraocular pressure quite a lot, and the sur-
face of contact with the cornea is flat. Docking for cataract
surgery requires the suction ring to adhere to the conjunc-
tiva, OCT procedures must be performed, ablation mainly
involves intraocular tissue, laser times are longer, and the
contact surface is curved to follow the curvature of the cor-
nea better and induces less increase of intraocular pressure.
 Laser-Assisted Cataract Surgery With the LenSx Femtolaser  169
Exposure of the eye: Very deep-set eyes, an excessively
prominent nose, reduced palpebral opening, and a cornea
that is too curved or too flat can make docking ineffective
and therefore laser-assisted surgery cannot be performed.
General conditions: Lack of cooperation from patients
for health reasons (Alzheimer’s, paralysis, muscular deficit,
and systemic pathologies) or excess anxiety can be contra-
indications to surgery. Nystagmus may be a contraindica-
tion only if eye movement is excessive.
Transparency of the cornea: To achieve its goal, the laser
beam must release its energy into the crystalline lens with-
out interference. Any corneal opacity or nebula can reduce
or block the passage of laser beams. This mainly affects the
capsulotomy that may be incomplete. The same applies to
action on the lens material and/or corneal tissue, even if
this is less important in the general context of the opera-
tion. Likewise, corneal edema (caused by some pathologies
of the cornea) can limit or block the transmission of the
laser.
Diameter of the pupil: In most cases, surgeons desire
a capsulotomy centered on the pupil, with a diameter
between 4.5 and 5.5 mm. Laser emission should also be at
least 1 mm from the edge of the pupil, so that iris pigment
Femtolaser Advantages
● The various corneal incisions are executed more
accurately and always performed in the same
way and with the same characteristics.
● Capsulotomy has a very precise diameter and site
and is very accurately centered, which provides
the best centering for the IOL and lens/capsu-
lotomy ratio, to the patient’s visual advantage.
● Can reduce the intraocular operations performed
by the surgeon and therefore the number of
internal maneuvers.
● Can reduce the time of surgery in the eye (but
not the overall duration of the operation).
● Can reduce the ultrasound energy emitted dur-
ing phacoemulsification.
● Can reduce the amount of fluid circulating in the
eye.
● Can be used to perform astigmatic keratotomy
operations with very accurate site, depth, and
extension, thus correcting mild preoperative
astigmatisms.
● Surgeons can perform surgery without knives or
other cutting instruments, which is psychologi-
cally very important for patients.
● The current limit is the high price. Despite the
price, femto technology has—at the time of writ-
ing this book—already become common prac-
tice in over 5000 international surgery centers of
excellence.
does not interfere with the passage of the laser energy (and
also because excessive proximity stimulates meiosis of the
pupil). Patients with a small pupil, pupils with synechiae,
or decentered pupils may not be suitable for laser surgery.
Depth of the anterior chamber: Increased distance
between the cornea and the anterior capsule of the lens
does not affect laser surgery, but a shallow chamber could
do so because the laser emission for capsulotomy may be
too close to the endothelium and damage this important
layer of cells.
SIDE EFFECTS AND COMPLICATIONS
As with any new technology, there is a learning curve
associated with the use of the femtosecond laser for cataract
surgery. This technique—like any other surgical proce-
dure—is not free of side effects and complications, mainly
intraoperative. It has been shown that the greater the num-
ber of operations performed, the lower the percentage of
complications (the decrease is significant). After the first
50 cases (learning curve), complications such as capsu-
lotomy escape or capsular rupture and/or dislocation of lens
material into the vitreous decrease dramatically. To begin
with, surgeons must learn to align the eye with the laser’s
optical system, to interpret the tomography images and to
adjust the laser’s parameters correctly. If these steps are not
performed properly, they can lead to complications and
side effects that even experienced surgeons may not be well
equipped to manage. The following are the main problems
that continue to need improvement:
1. Difficulties making the incisions: It is sometimes dif-
ficult to position the entrance of the tunnel for phaco-
emulsification correctly during the programming
phase. If the entrance ends up in a vascularized area
or in any nontransparent area of the cornea, the cor-
neal incision will be incomplete and the surgeon will
have to use a knife. The same applies to accessory
incisions. Sometimes, the position of the incision ends
up being too anterior in the cornea, which makes
intraocular maneuvers challenging. The incision can
be too oblique, which hinders the surgeon and can
induce mild, irregular astigmatism. Finally, relaxing
incisions for the correction of astigmatism require
nomograms that make the results more predictable and
reproducible.
2. Problems (occasional) obtaining a complete capsuloto-
my: This can be caused by a number of factors, such as
corneal folds induced by docking (which can interfere
with the laser beam propagating evenly and uni-
formly), more or less opaque areas in the cornea, scars
left by wounds or ulcers, scars resulting from corneal
surgery—all can interfere with optimal transmission
of laser energy. Dishomogeneous capsular density can
cause incomplete cleavage. However, delta up and delta
170  Chapter 13
Figure 13-18. Femtophaco. (A) Laser programming: site of the incisions, positioning of an arcuate keratomy, capsulotomy diameter
and site; in the upper right, detail of capsulotomy programming and below programming of the nucleus thickness to cut. (continued)
down, associated with the correct quantity of energy
emitted per shot, make this occurrence rare. Other
factors causing incomplete capsulotomy, as mentioned
above, are docking with tilting or loss of suction during
laser emission. Palanker et al reported the presence of
microgrooves at the edge of the anterior capsulotomy,
with the formation of small folds that can make capsu-
lar ruptures more likely to develop.2 For this reason, it
is important that the capsulotomy is completed manu-
ally with forceps, with the aim of stopping the micro-
incisions of the anterior capsular edge from spreading
equatorially and posteriorly. If loss of suction occurs
during laser emission, the femtocapsulotomy will be
incomplete. In this case, an experienced surgeon can
repeat the docking procedure and program a larger
diameter for the capsulotomy.
3. The presence of lens dust in the anterior chamber
that reduces visibility: This problem may arise during
removal of the anterior capsule and during hydrodis-
section. As mentioned above, the emission of the laser
spots begins 300 to 400 μm below the anterior capsule
(delta down) and ends about 300 μm above (delta up).
Laser emission therefore occurs intensely also on the
anterior epinucleus, which causes lens dust to move
and some of it will enter the anterior chamber through
the incisions of the anterior capsule, reducing visibility
for the surgeon. Another important element that limits
visibility to surgeons is the presence of plasma bubbles
in the lens material. The higher the energy released
in the lens, the larger the amount of bubbles. Bubbles
are also related to the segmentation pattern. Visibility
is also reduced if a cylindrical pattern is used because
the cylinders affect the very core of the nucleus and
are below the capsulotomy. Furthermore, they are very
close to each other and create turbidity.
4. Partial constriction of the pupil: Intraoperative mio-
sis is the result of the emission of laser energy in the
anterior chamber and near the pupil margin and may
be caused by direct stimulation of the iris or release of
prostaglandin. Miosis can make phaco more difficult
and hinder correct positioning of the IOL, especially
with toric or special designs. This side effect—miosis,
which can be a problem for the surgeon—can, in part,
be prevented by adding a drop of 10% phenylephrine
at the end of the laser procedure and before the actual
surgery. To prevent laser-induced miosis, the use of
a 1% atropine solution before surgery and the use of
preservative-free adrenalin in the irrigation bottle dur-
ing surgery can be helpful. The time between the laser
procedure and surgery should be as short as possible.
5. The need to perform hydrodissection very delicately:
The capsular bag has already been distended by the
bubbles released during laser ablation, so delicate
hydrodissection is necessary to keep the volume of the
capsular bag from expanding (which could ultimately
cause the bag to rupture). Inadequate hydrodissection
 Laser-Assisted Cataract Surgery With the LenSx Femtolaser  171

C D

E F

Figure 13-18. (continued) (B) Laser emission on the capsule has already been performed and now the laser is cutting the nucleus.
(C) Under the operating microscope, the capsulotomy and splitting of the nucleus in 4 quadrants can be seen. (D) The corneal inci-
sions are opened with a blunt spatula, followed by viscoelastic injection. (E) The anterior capsule cut by the laser is removed with
forceps. (F) Buratto’s prechopper is used to completely widen the incision made by the laser in the nucleus (which did not cut the
deepest part of the nucleus). (continued)
172  Chapter 13

G H

I J

K L

M N

Figure 13-18. (continued) (G) Further division of the nucleus to release the gas that formed inside the capsular bag due to the
laser treatment. (H) Hydrodissection is performed carefully. (I) A first quadrant is captured by putting the U/S tip in occlusion.
(J) Beginning of nucleus emulsification. (K) Another quadrant is emulsified. (L) I/A with 2-handed technique proposed by Buratto in
1992. (M) Completion of 2-handed I/A. (N) A perfect capsulotomy is shown. (continued)
 Laser-Assisted Cataract Surgery With the LenSx Femtolaser  173

O P

Q R

Figure 13-18. (continued) (O) After filling the anterior chamber with viscoelastic substance, the 1-piece acrylic IOL Alcon Acrysof
is injected. (P) Removal of viscoelastic below the lens. (Q) Final view with IOL perfectly centered on the capsulotomy. (R) Opening
using forceps of the astigmatic keratomy positioned in place opposite the main incision.

is associated with a number of small problems that
make the operation more complex.
To begin with, the epinucleus and the cortex adhere
more strongly, so more traction and time are required
to remove them. This may also be caused by the fact
that the gas bubbles released when the nuclear incisions
are created make the cortex adhere more strongly to
the residual anterior and equatorial posterior capsule.
Furthermore, more fragments of lens remain on the
posterior capsule, which require scraping/cleaning
procedures of the posterior capsule that take longer
than those with traditional hydrodissection after cap-
sulorrhexis with forceps or a cystotome. In any case,
the removal of the cortex is easier to perform with
the Buratto bimanual technique because it is easier to
access the capsular bag (360 degrees).
6. Incomplete fragmentation of the nucleus: The effect of
the laser may not be sufficient to segment very dense
nuclei, so the ablation may not create defined grooves
that can be transformed into cuts using a prechop-
per, chopper, or other tools for nuclear fragmentation.
In most cases, the surgeon must be able to manage a
nucleus where only the surface is fragmented and there
is a “posterior bowl” of nucleus that was not fragment-
ed because of proximity to the posterior capsule. If the
cataract is not hard, flipping the nucleus or sculpting
to achieve complete fragmentation is recommended.
7. The formation of large gas bubbles: Some appear
immediately in the anterior chamber, along the edges
of the capsulotomy. Other gas bubbles form inside the
lens nucleus and can cause iatrogenic damage. The
gas generated during the laser procedure increases the
intracapsular volume and rarely—in inappropriately
managed cases—the posterior capsule may break and
the lens may be dislocated into the vitreous humor.
This is partly caused by an increase in intracapsu-
lar pressure but primarily by incorrect hydrodissec-
tion that can further increase intracapsular pressure.
Predisposing factors include posterior polar cataracts,
mature cataracts, long axial length, and rapid, excessive
hydrodissection. To avoid this complication, surgeons
should do the following:
● Avoid filling the anterior chamber completely with
viscoelastic material before removing the anterior
capsule.
● Lift the edge of the anterior capsule during
hydrodissection.
● Inject the fluid for hydrodissection slowly, using the
expansion of the visible wave as a reference point.
● Decompress the anterior chamber before and dur-
ing hydrodissection by applying pressure on the
posterior lip of the corneal incision.
174  Chapter 13
● There is no doubt that the most effective method
is using a prechopper or a chopper (or even a can-
nula) to fragment the nucleus of the lens, in order
to release the gas and/or liquid, and performing
hydrodissection only after the release has occurred.
8. Posterior capsular rupture and nucleus dislocations:
This is mainly caused by radial tears in the anterior
capsule extending posteriorly. It is crucial that any
microincisions at the edge of the capsulotomy are
anticipated and managed carefully. The microincisions
are caused by the incomplete incision of the capsule by
the laser or because the surgeon is unable to see capsu-
lar connections remaining after the laser treatment or
by other factors (tilting of the lens, corneal opacity, and
capsular thickening).
9. Not being able to perform any kind of infiltration
anesthesia before the laser treatment because it would
hinder the docking process. Infiltration anesthesia if
needed can be performed after laser treatment and
before phacoemulsification. It can be said that the
femtosecond laser is the road to follow to further
improve cataract surgery—the next steps will be the
use of laser in other steps of the procedure, the lique-
faction of the crystalline lens, and new increasingly
customized IOLs. As the Russian philosopher and
revolutionary Mikhail Bakunin said, “By striving to do
the impossible, man has always achieved what is pos-
sible. Those who have cautiously done no more than
they believed possible have never taken a single step
forward” (Figure 13-18).
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laser-assisted cataract surgery with integrated optical coherence
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 FINANCIAL DISCLOSURES
Dr. Stephen F. Brint has no financial or proprietary interest in the materials presented herein.

Dr. Lucio Buratto has not disclosed any relevant financial relationships.

Dr. Almudena Valero Marcos has not disclosed any relevant financial relationships.

Dr. Marίa José Pérez Morales has not disclosed any relevant financial relationships.

Dr. Zoltan Z. Nagy has not disclosed any relevant financial relationships.

Dr. Francisco Javier Martínez Peña has not disclosed any relevant financial relationships.

Dr. Joaquίn Fernández Pérez has not disclosed any relevant financial relationships.

Dr. Stephen G. Slade, MD has not disclosed any relevant financial relationships.

Dr. Rosalia Sorce has not disclosed any relevant financial relationships.

Dr. Pavel Stodulka is a consultant to Bausch & Lomb and has received travel grants from Technolas.

Dr. Daniele Tognetto has not disclosed any relevant financial relationships.

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