(REVISI) The Preparation of Phacoemulsification - Faraby Martha MD

Basic of Phacoemulsification
PRESENTED ON REVIEWS, Makassar Dec 2020
THE PREPARATION OF
PHACOEMULSIFICATION
(REGULAR CASE/DIFFICULT CASE
Faraby Martha, MD
Department of Ophthalmology
Cornea, Cataract, and Refractive Surgery Division
RSCM Kirana- Universitas Indonesia
RSCM KIRANA Jln. Kimia No.8, Jakarta Pusat, 10320 - Twitter/Instagram @rscmkirana - E-mail mata.rscmkirana@gmail.com
• No Financial Interests
OVERVIEW
• Phaco • Safety Checks • Know your • Prepare to
training • Comfortable machine convert
• Case Position • The Instruments
selection • Draping and • The medications
Sterility
Outside Beginning of During

Prior to OR
OR Operation Operation
1. Gupta R. Phacoemulsification Cataract surgery. Spriger. 2017
Phaco Training
Case
Closeselection
supervision
Structured training
Phaco Structured Training
70–80 phacoemulsification cases to

In Ophthalmology Department RSCM: obtain expert surgical skills.
3 mo: ECCE Minimum:60

3 mo:ECCE
+Phacoemulsification surgeries
Didactic sessions Self Assessment is Mandatory!!!

and wet labs
(2 Weeks) • Attention to details
• Record If Possible
Randleman JB. Arch Ophthalmol. 2007
Objective Structured Assessment of Cataract Surgical Skill (OSACSS)
(p>0.05)
P h a c o Tr a i n i n g (p>0.05)
1 0 0 F i r s t (p<0.05)
S u rg e r i e s 79 (65-90)
80 (45-86)
S e n i o r
R e s i d e n t 69.42±12.7
R S C M K i r a n a Phacoemulsification score
1st 30 2nd 30 3rd 40

Close Supervision
Anterior segment surgeons with extensive
phacoemulsification experience
Superviser taking over the case

Safety of the patient
Resident confidence
Sequential training, Reverse Training, Modular, Time

limited
Kaplowitz, K.Survey of Ophthalmology, 2017
What technique should I
Choose??
Beginner Divide Stop and Phaco
Surgeon and Chop Chop
Conquer
ORCI LUCTUS ET ULTRICES
POSUERE CUBILIA CURAE;
DONEC
CDE
Medium + + ++
Cat
Vestibulum ante ipsum primis in faucibus orci luctus et
ultrices posuere cubilia Curae; Donec velit neque, auctor
sit amet aliquam vel, ullamcorper sit amet ligula. Nulla
quis lorem ut libero malesuada feugiat. Vestibulum ac
CDE Hard
Cat + ++
diam sit amet quam vehicula
Technically
Easy +++ +++
Case Selection
Potential Complication Cases Potential Complication

(Immediate and late)
Soft Cataract
Posterior capsule Rupture
Brown “ Hard Nucleus” Cataract
High Myopic Patients/ Post Vitrec Cataract

Nukleus drop/ IOL Drop
Smal Pupils (Potential IFIS)
Pseudoexfoliation (PXF) Prolonged Surgery-corneal edema
Very shallow ACD/ Low ECD
Safety Checks
Pre-operative checks
Patient verification
Preventing wrong eye surgery
Preventing insertion of the wrong intra ocular lens
Maintaining sterility
Accidentally become unsterile
Need to change gloves, microscope handles, or surgical instruments
Gupta R. Phacoemulsification Cataract surgery. Spriger. 2017
Comfortable Position
Poor posture  Uncomfortable position  Surgical outcome
 Trolley can be adjusted to a suitable height

 The microscope should be also be adjusted
 The eyes pieces angled correctly
 Raise the foot pedals
 Handing sharp instruments back
“protect your neck, protect your back”
Draping and Sterility
Endophthalmitis Incidence: 0.04%- 0.2%
Povidone-iodine 5% (Ocular), 10%

(Skin)
Nguyen. European Journal of Ophthalmology,. 2017
Draping and Sterility
Later skills taught to novice surgeons

Poor draping can lead to anxiety of Trainee
Phaco Machines
AFR
Va c u m
US Power
Tinggi Botol/
IOP
Grip
(vacuum)
Power
(US)
Speed Space
(AFR ) (BH)
Mode Mesin Parameter Peristaltik Venturi
Phaco 1 (Sculpting) Tinggi Botol 80 cmH2O 80 cmH2O
US Power 70% (Linier-Cont) 70% (Linier)
Vakum 60 mmHg 50 mmHg
AFR 30 ml/min -
Phaco 2 (Chopping) Tinggi Botol 100 cmH2O 100 cmH2O
US Power 60% (Burst) 60% (Burst)
My Beginner Setting

AFR 35 ml/min -
Phaco 3 (Quadrant Removal) Tinggi Botol 90 cmH2O 100 cmH2O
US Power 50% (Pulse) 50% (Pulse)
AFR 32 ml/min -
Phaco 4 (Epinukleus) Tinggi Botol 80 cmH2O 90 cmH2O
US Power 40% (Pulse) 40% (Pulse)
AFR 25 ml/min -
Irigation Aspiration Vakum 500 mmHg 500 mmHg
AFR 35 ml/min -
The Instrument and Surgical Armamentarium
Difficult (Special) case:

Zonulysis, High Miopia
Capsular support device
Small Pupil, PXF Pupil Expander device
Hard/ soft Cat Nucleus Chopper
Hipermature cat, caps Fibrotic Forceps & Vannas
PCR, NO capsule support Special IOL
Zonulysis, High
Miopia
< 4 Clock
Hours/ 120
Capsular Support Devices CAPSULAR TENSION
RING (MODIFIED)
CAPSULAR TENSION “CIONNI RING”
RING
• Increasing the capsular bag
placement of an IOL
CAPSULAR
RETENSION HOOK
CAPSULAR TENSION
SEGMENT
Morcher GmbH, Stuttgart, Germany.
Zonulysis, High Miopia
The art of placing of CTR

“as late as you can, but as soon as you must”
J Cataract Refract Surg 2013; 39:1904–1915
Small Pupil, PXF
a) Pupillary membrane
Dissection
b) Lysis of posterior synechia
c) Viscodilation Osher Y-hook
d) Pupil stretch
e) Minisphincterotomies
f) Iris hooks, pupil ring
expanders
Atonic pupil !!!
Kuglen Iris Hook
Fine IH. Cataract surgery: third Ed. Elsevier. USA.2010.
Bimanual stretch maneuver
Micro Scissors
Utrata Forceps
Pupillary membrane Dissection Spincterotomies

Small Pupil, PXF
Malyugin Ring
Pupil Expander device
Iris Hooks

Hard/ soft Cat
Vertical Chopper
Chang Chopper
Seibel Chopper
Seibel BS. Phacodynamics. USA: SLACK incorporated. 2005

Chang FD. USA: SLACK incorporated. 2004
Horizontal
Chopper
Microfinger Chopper Nagahara Karate Chopper
Seibel BS. Phacodynamics. USA: SLACK incorporated. 2005 Chang Microfinger Chopper Olson Chopper
Hard/ soft Cat
Akahoshi sustainer
Akahoshi PreChopper
Sinskey Hook
Seibel BS. Phacodynamics. USA: SLACK incorporated. 2005
PCR, NO capsule support
I n t h e B a g I O L + I n t h e S u l c u s I O L
O p t i c c a p t u r e I m p l a n t a t i o n
1 2 3
A n g l e I r i s
T S F / I S F
S u p p o r t e d C l a w
I O L I O L
The Medications (Intracameral)
Mydriatics
Nonpreserved epinephrine (1:1000) dilute with BSS 1:9----1 ml
Anesthetics
Intracameral isotonic nonpreserved lidocaine 1% (Xylocain 2% dilute 1:1) ------0.5 ml
Staining Agent
Tryphan blue---0.2 ml
Miotics
Parasympathomimetics :Carbachol 0.01%---0.2 ml
Prophylactic antibiotics TASS !
Irrigating solution VS Intracameral antibiotics !!
Gentamicin (Irrigating solution) ---0.3ml/500 ml
Moxifloxacin 0.5% (Intracameral) Vigamox®--- 0.05 ml
Levofloxacin 0.5% (Intracameral) Cravit® ---0.05 ml
Arshinoff SA, Opalinski YA, Podbielski DW. The pharmacotherapy of cataract surgery. In: Yanoff M, Duker JS. Ophthalmology. 5 ed. Elsevier. USA:2019.
Ingredient Human Aqueous BSS
Irrigating Solution Humor
Sodium 162.9 155.7
Potassium 2.2- 3.9 10.1
 Normal saline Calcium 1.8 3.3

Magnesium 1.1 1.5
 Lactated Ringer’s solution Chloride 131.6 128.9
Bicarbonate 20.15 -
 BSS Phosphate 0.62 -
Lactate 25 -
Glucose 2.7-3.7 -
Ascorbate 1.06 -
Glutathion 0.0019 -
Citrate - 5.8
Acetate - 28.6
PH 7.38 7.6
Osmolality 304 298
Arshinoff SA, Opalinski YA, Podbielski DW. The pharmacotherapy of cataract surgery. In: Yanoff M, Duker JS. Ophthalmology. 5 ed. Elsevier. USA:2019.
Prepare to convert
6 Weeks:
90.0% BCVA of 20/40 or better, Cause Number (%)

70.0% BCVA of 20/20 of Cases
Pupillary Miosis 6 30%
ECL in Convert cases 14.8% PCR 5 25%
(VS 7.2% in Succesfull phaco cases)Prolonged phaco time 4 20%
Posterior extension of capsulorhexis 2 10%
Corneal thermal burn 1 5%
Lens subluxation 1 5%
Phaco machine malfunctioning 1 5%
Dada, T. Conversion from phacoemulsification to extracapsular cataract extraction: Incidence, risk factors, and visual outcome. Journal of Cataract and Refractive Surgery. 1998
Referrence
2. Dada, T., Sharma, N., Vajpayee, R. B., & Dada, V. K. (1998). Conversion from phacoemulsification to
extracapsular cataract extraction: Incidence, risk factors, and visual outcome. Journal of Cataract and
Refractive Surgery, 24(11), 1521–1524. https://doi.org/10.1016/S0886-3350(98)80177-6
3. Arshinoff SA, Opalinski YA, Podbielski DW. The pharmacotherapy of cataract surgery. In: Yanoff M, Duker JS.
Ophthalmology. 5 ed. Elsevier. USA:2019. section 5.7. page 357-405
4. Nguyen, C. L., Oh, L. J., Wong, E., & Francis, I. C. (2017). Povidone-iodine 3-minute exposure time is viable in
preparation for cataract surgery. European Journal of Ophthalmology, 27(5), 573–576.
https://doi.org/10.5301/ejo.5000964
5. Seibel BS. Phacodynamics: Mastering the tools and techniques of phacoemulsification surgery. USA: SLACK
incorporated. 2005; 3: 240-324.
6. Chang FD. Phaco Chop and Advanced Phaco Techniques; Strategies for complicated cataract. Second Ed. USA:
SLACK incorporated. 2004; 2: 85-139
7. Fine IH, Packer M, Hoffman RS. Phacoemulsification in the presence of a small pupil. In: Steinert RF. Cataract
surgery: third Ed. Elsevier. USA.2010. Chapter 21. page 245-57
8. Kaplowitz, K., Yazdanie, M., & Abazari, A. (2018). A review of teaching methods and outcomes of resident
phacoemulsification. Survey of Ophthalmology, 63(2), 257–267.
https://doi.org/10.1016/j.survophthal.2017.09.006
9. Randleman JB, Wolfe JD, Woodward M, Lynn MJ, Cherwek DH, Srivastava SK. The resident surgeon
phacoemulsification learning curve. Arch Ophthalmol. 2007;125(9):1215–1219.
doi:10.1001/archopht.125.9.1215
Thank You

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Basic of Phacoemulsification

PRESENTED ON REVIEWS, Makassar Dec 2020

Outside Beginning of During

1. Gupta R. Phacoemulsification Cataract surgery. Spriger. 2017

70–80 phacoemulsification cases to

3 mo: ECCE Minimum:60

Didactic sessions Self Assessment is Mandatory!!!

1st 30 2nd 30 3rd 40

Superviser taking over the case

Sequential training, Reverse Training, Modular, Time

Potential Complication Cases Potential Complication

High Myopic Patients/ Post Vitrec Cataract

Gupta R. Phacoemulsification Cataract surgery. Spriger. 2017

Poor posture  Uncomfortable position  Surgical outcome

 Trolley can be adjusted to a suitable height

1. Gupta R. Phacoemulsification Cataract surgery. Spriger. 2017

Endophthalmitis Incidence: 0.04%- 0.2%

Povidone-iodine 5% (Ocular), 10%

Nguyen. European Journal of Ophthalmology,. 2017

Later skills taught to novice surgeons

1. Gupta R. Phacoemulsification Cataract surgery. Spriger. 2017

Vakum 400 mmHg 350 mmHg

Difficult (Special) case:

1. Gupta R. Phacoemulsification Cataract surgery. Spriger. 2017

Morcher GmbH, Stuttgart, Germany.

The art of placing of CTR

Pupillary membrane Dissection Spincterotomies

Pupil Expander device

J Cataract Refract Surg 2013; 39:1904–1915

Seibel BS. Phacodynamics. USA: SLACK incorporated. 2005

Microfinger Chopper Nagahara Karate Chopper

 Normal saline Calcium 1.8 3.3

90.0% BCVA of 20/40 or better, Cause Number (%)

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