PHACODYNAMIC

S Haitham Al
Mahrouqi April
2018
REFERENCE
S
➤ AAO BCSC: Lens and cataract

➤ All India Ophthalmological Society: A guide to phacoemulsification. Can

be accessed from http://www.aios.org/cme/cmeseries21.pdf
➤ Phaco Fundamentals for the Beginning Phaco Surgeon. By Uday Devgan
UNDERSTANDING
PHACOEMULSI F I
C ATI O N
➤ Phacoemulsification is a dynamic procedure requiring understanding of the:

➤ Machine
➤ The functions of the machine
PHACODYNAMIC
S
➤ Definition

➤ The various functions of the phaco machine and their inter relationship

➤ Functions of phaco machine:

➤ Ultrasonic power
➤ Irrigation and aspiration system (A.K.A fluidics)
ULTRASONIC
POWER
➤ Phaco power is generated by vibrations of quartz
crystals in the hand piece.
➤ Quartz is silicone oxide and is peizoelectic: That
means if you squeeze a quartz crystal, it generates
a tiny electric current. The opposite is also true:
if you pass electricity through quartz, it vibrates
at a precise frequency (it shakes an exact number
of times each second).
➤ As well as being used in watches to calculate each
second, it is used in the phaco tip.
ULTRASONIC
POWER
➤ The frequency of quarz crystal vibrations is variable from
29–60 KHz in different machines.
➤ High frequency of vibrations (from more quartz crystals
or more electric power) results in better cutting but may
result in more heat generated.
➤ In each machine the vibrations (oscillations) are fixed
but the power is modulated by changing the stroke
length (axial or torsional).
➤ Power = oscillations (fixed/constant) x stroke length
➤ Energy: power x time
MECHANISM OF
EMULSIFICATION
➤ Jack-hammer: Mechanical bombarding
of the tip (axial or torsional).
➤ Cavitation: Mainly by axial movement
of the tip.
➤ Acoustic wave of fluid: From the
forward (little with tortional)
movement of the tip pushing fluid away
which can integrate soft lens matter.
Jack Hammer effect: The
rapid to and fro movement of
the tip bombards the tissue
in front and disintegrates it
Cavitation phenomenon:
The frequency of oscillation
is 40,000/ second. The
swift backward movement
of the tip results in a
cavitation phenomenon
causing an implosion of
surrounding tissue.
WHAT IS OZIL
IP?
➤ Pure torsional jackhammer effect
clogs the needle.
➤ OZIL IP is an intelligent system
sensing that the needle is clogged and
vacuum rises where which it will
activate the axial oscillation for
cavitation.
➤ Advantages: More efficient cutting,
less heat and more stable AC.
Jack Hammer effect: The
rapid to and fro movement of
the tip bombards the tissue
in front and disintegrates it
Cavitation phenomenon:
The frequency of oscillation
is 40,000/ second. The
swift backward movement
of the tip results in a
cavitation phenomenon
causing an implosion of
surrounding tissue.
PHACO
TIP
➤ The higher the angulation the lesser the
holding power and the more the cutting and
visa versa.

➤ For divide and conquere: use 45* (trenching is

important)
➤ For stop and chop: use 30* (holding is very
important).
POWER
DELIVERY
➤ Power = oscillations (fixed) x stroke length

➤ Two modes for power delivery:

1. Surgeons mode (A.K.A linear /continuous):
the power varies from 0 - maximum Phaco power

according to the depression in the foot pedal

Extent of depression of position 3
in position.

Phaco power

2. In the panel mode: power is maximum in all

Extent of depression of position 3
of position 3.
POWER
DELIVERY
➤ Variations of the continuous mode include
pulse mode: variable intervals of on and
off at a particular phaco power (equal
on and off time).
➤ Variation of the panel mode include the
burst mode, however, now can be also made
into a linear mode: Depression on the foot
pedal in position 3 varies the time between
the intervals.
➤ Both are aimed at decreasing the absolute
phaco time (energy) as well as using the
vacuum to help with removal of the cataract.
POWER
CALCULATI O N
➤ Calculate the absolute phaco time
(energey) if in 1s there are 5 pulses of F^WYe Fkbi[
100ms duration and a similar pauses of
phaco.

E]VXdEdlZg 3
➤ 5 x 100ms = 0.5s
➤ In phaco machine: ;ddi EZYVa 9ZegZhh^dc ^c Edh^i^dc ( 3

Figure 2

7FJ0 7Xiebkj[ F^WYe J_c[ 8dci^cjdjh :cZg\n 9Za^kZgn

6 E I 2 E]VXd I^bZ × 6kZgV\Z E]VXd EdlZg
&* hZXdcYh × &%%% edl Zg 2 &*
KVg^VWaZ Edl Zg YZeZcY^c\
hZXXdcYh 6EI (% hZXdcYh × *%%
edl Zg 2 &* hZXXdcYh 6EI
dc [ddi eZYVa YZegZhh^dc
+% hZXdcYh × 2*% edl Zg 2 &*
hZXXdcYh 6EI

Id 9 ZXgZVhZ 6EI
9ZXgZVhZ E]VXd I^bZ
9ZXgZVhZ 6kZgV\Z E]VXd Edl Zg
FLUIDIC
S
➤ Fluidics in phaco refers to the integrated system of irrigation and aspiration
where the A/C volume is kept stable.
➤ Phaco has a major advantage over ECCE in that it is performed in a closed system
thus avoiding damage to the cornea, iris…etc.
IRRIGATIO
N
➤ The inflow of BSS into the eye is governed by the
pressure gradient at the tip of the phaco probe:
that is the pressure difference between the
positive pressure created by the bottle height
(gravity) and the negative pressure created by the
aspiration port.

➤ Newer machine have an active infusion where

there is a sensor at the phaco tip. This allows
active control of the IOP during the surgery.
IOP
CALCULATI ON
➤ What is the IOP in the A/C when the bottle height is 60cm?

➤ 60 cm = 600 mm water column, 600/13.6 = 44 mmHg (Roughly 75% of the

bottle height).
WHAT IS THE PROBLEM WITH EXCESSIVE BOTTLE
HEIG HT?
➤ Increased irrigation leads to:

➤ Pushing the iris lens diaphram leading to zonular stress

➤ Irritation to the iris resulting in miosis
➤ Overfilling the A/C leads to excessive leaking and iris prolapse.
WHAT IS THE PROBLEM WITH TOO LOW BOTTLE
HEIG HT?
➤ reduced irrigation leads to:

➤ Fluctuations of the IOP with A/C collapse

➤ Injury to the introcular structures
ASPIRATION
SYSTEM
➤ To emulsify the cataract: Figure 1

1. There needs to be lavage (sucking) of the cataract to the tip Phaco Foot Pedal Function
of the phaco probe: This is governed by the flow rate.
Irrigation = 1
2. Holding power of the cataract to the phaco tip so it does not Aspiration = 2
slip away: This is governed by the vaccum created by the
Ultrasound = 3
phaco machine.

➤ Therefore there are two types of aspiration systems

(pumps):
1. Flow based system: Peristaltic
2. Vacuum based system: Venturi
VACUUM BASED PUMP :
VENTURI
➤ Direct control of the vacuum and indirect
control of the flow rate.
➤ The amount and speed of gas through the
tubing governed by the depression in
position controls the amount of vacuum and
thus flow rate.
➤ The relationship of the vacuum created to the
flow rate is not linear (modified by the port
size and tubing).
➤ The advantage of this system is that the
vacuum is directly transmitted to the tip from
the system ensuring a better followability.
FLOW BASED PUMP :
PERIS TALTI C
➤ Direct control of the flow rate and indirect
control of the vacuum (only max can be set).
➤ Flow rate is the amount of fluid aspirated from
the A/C per unit time.
➤ The rollers compress the silicone tubing to
withdraw the fluid in the drainage bag. The
larger the depression in position 2 the faster the
movement of the rollers and thus higher flow
rate.
➤ Vacuum is only built up when the tip is occluded
and negative pressure builds inside the tubing.
FLOW RATE IN
PERSTALTI C PUMP
➤ Normally between 20-36 cc/min

➤ What happend if flow rate is slow?

➤ Slow surgery and flowability to the tip is decreased
➤ What happens of flow rate is too fast?
➤ Surgery will be uncontrolled and cataract pieces may slip away as the rollers
may slip from the tubing decreasing the effectiveness.
VACUU
M
➤ Double edge sword

➤ How does vacuum in peristaltic pump build?

➤ Only after occlusion. It governs the holding power.
The rise time to the maximum vacuum is governed
by the flow rate.
➤ How does the phaco port size affect the
vacuum?
➤
Inversely proportional
FLOWABILITY
➤ A concept to refer to the tendency of the
cataract fragments to be attracted to the phaco
tip.
➤ The positive pressure due to the infusion and
the negative pressure created by the aspiration
pump are responsible for the creation of a
pressure gradient at the tip.
➤ This in turn leads to eddy currents from the
infusion orifice to the phaco tip.
➤ The area encompassed by these eddy currents
is known as the zone of followability
➤ Any other areas of no followability?
TUBING
S
➤ To maintain a formed A/C:

Inflow of BSS (irrigation) > outflow (aspiration) + wound leak

TUBING
S
➤ Poiseuille’s law: Resistance to flow
TUBING
S
➤ Describe the difference in phaco tubings Figure 1

and why?
9ecfWh_ied e\
Ekj\bem WdZ ?d\bem JkX_d]

I de / hbVaa! g^\^Y dji[adl ijW^c\#

7 d i i d b / aVg\Z! [aZm^WaZ ^c[adl
ijW^c\
SURG
E
➤ Post occlusion surge occurs during occlusion Figures 2, 3, 4
of the phaco tip with a nuclear fragment and
vacuum builds up; the pressure inside the 9ebbWfi[Z JkX_d] Ijeh[ i
outflow tubings is high with collapse of its ;d[h]o
walls. Once the fragment is removed, the dXXajh^dc d[ ijW^c\
$ i^e l^i] XVigVXi
tube rebounds creating -ve pressure and A/C
Xdb ea^Vci
collapses risking injury to posterior capsule. ij W^c\
XdaaVehZh VcY
hidgZh ZcZg\ n

edhi"dXXajh^dc
hjg\Z l ] Z c
ijW^c\
gZWdjcYh

8dbea^Vci ijW^c\ XVc XdaaVehZ

VcY XVjhZ hjg\Z Yjg^c\ XViVgVXi
hjg\Zgn#
HOW TO PREVENT
SURGE?
1. Tubings
2. Using of cassette (to decrease the
compliance of the tubings)
3. Smart machine:
A. Venting
B. Delay the start of the motor following
occlusion break
C. Different settings of the flow
rate/ vacuum before and after
occlusion breaks
HOW TO PREVENT
SURGE?
4. Smart Surgeon
• Awareness of the phacodynamics
• Decreasing the effective flow rate by using lower phaco
tip.
• Using viscoelastic to decrease the inflow of BSS and surge
• Proper wound construction
• Foot pedal control
DIAPHRAGM
PUMP
➤ Consists of a flexible diaphragm overlying a fluid chamber with 1-way valves at
the inlet and outlet.
➤ The diaphragm moves out, creating a relative vacuum in the chamber that
shuts the exit valve, causing the fluid to flow into the chamber.
➤ The diaphragm then moves in, which increases the pressure in the chamber and
closes the intake valve while opening the exit valve
➤
TECHNIQUES OF NUCLEUS REMOVAL DURING
PHACO
➤ Divide and conquer Figure 4

Place Instruments
Deep in the
Groove
Rotate & Create 4 Deep placement allows for
comlete
Quadrants cracking and separation of
the nuclear pieces
Maintain the Squared Grooves to
facilitate cracking of the nucleus into SHALLOW
quadrants.
DEEP

2 HALVES 4 QUADRANTS BAD GOOD

incomplete crack complete crack
TECHNIQUES OF NUCLEUS REMOVAL DURING
PHACO
➤ Stop and chop Figure 1

Step 1. Figure 2

Make a groove & crack

Step 2.
Allows more room for placement of Now Chop Each Half
the phaco probe and second
instrument

Make a Groove

Crack into
Halves
CENTRAL SAFE
ZONE
THANK
S