Phacoemulsification

1. By
Bahaa Halwany
Department of Ophthalmology
Medicals international

2. A. Basic principles of Phacoemulsification
B. Anesthesia
C. Fluid Dynamics
D. Parts of Phacoemulsifier
E. Phacoemulsification surgery
F. Phacoemulsification risks

4. Phacoemulsification was first introduced in 1967 by Charles
Kelman and emerged as an efficient and fast variation of
extracapsular cataract extraction surgery
Advantages of Phacoemulsification over ICCE
Small incision (reducing healing time, postoperative astigmatism,
flattening of the chamber, hemorrhagic complications, number of
sutures)
Conservation of posterior chamber, vitreous body, avoiding retinal
detachment
Better and complete aspiration of the cortex
Easy implantation of the IOL in the posterior chamber

5. The nucleus change color from transparent to gray,
yellowish, amber, amber brown, black
The color of the nucleus is clear evidence of the degree of
cataract (the darker  the harder)
Optimum condition for phaco is grade 3, moderately yellow
and mostly exists in senile cataracts age 60-65

6. The density of the nucleus is identified using a microscope
with coaxial light.
When a red reflex is formed with diffusion, a soft nucleus is
identified (as nucleus hardens, luminosity ↘)

7. The cornea needs to be transparent to
undergo Phacoemulsification technique.
Transparency of cornea detected by specular
microscopy.

8. The iris should be widely and durably dilated
throughout the phaco process
The chamber’s depth is left normal
If it is reduced it is difficult to manipulate the U/S tip
If it is increased, then less control over Interoperative
steps as the microscope’s field diminishes
Chamber depth:

9. Uveitis, glaucoma, retinal detachment…
might interfere with phaco process
Phaco should then be avoided

11. Performed on patients who are unsuitable for local
anesthesia such as children, psychopaths,
complicated surgeries, or with beginner surgeons.
Advantages Disadvantages
Immobility of patients Postoperative complications, hypertension
Intact eye anatomy More expensive
No restriction on time of surgery
Prolonged ocular hypotension

12. Not to be used with children or psychopaths.
Prior to local anesthesia:Atropine and
ansiolytic drug like valium are to be given to
the patients.

13. Methods of local anesthesia Description
Retrobulbar injection This injection provides akinesia of the extraocular muscles, thereby
preventing movement of the globe.
• O’brien technique to block the conduction of the facial nerve at the
mandibular condyle
• Van lint technique to block the distal fibers of the facial nerve at the
lateral edge
Eye is then compressed for 30-40 seconds
Peribulbar infiltration • Needle introduced into lower eyelid above the orbit edge
• Reaching the tissues around the muscular cone
• That are anesthetized by diffusion.
•Eye is then compressed for 30-40 seconds
Sub-Tenon’s block • Local anesthetic agent into the sub-Tenon’s space,
•Blocking the sensation from the eye by action on ciliary nerves
•Akinesia by direct blockade of motor nerves.
Advantages: less painful than the retrobulbar block, no serious
complications, no increase in intraocular pressure while administering
the anesthetic, surgery can commence immediately

14. Include teracaine or lidocaine
No pressure on the eye is required

16. The system concerned in phaco include:
 Bottle with irrigation liquid
 An irrigation tube
 The eyeball
 An aspiration tube
 An aspiration pump

18. Flow rate
Vacuum and occlusion
Venting
Reflux

23. Machine body:
- Controls irrigation, flow rate, aspiration, and production
of the magnetic field
Connection system:
- Uniting the handles and cassettes of the machine

24. The ultrasonic probe
The I/A handpiece
Diathermy handpiece
Anterior vitrectomy handpiece

25. Four positions:
 Position 0: stand by
 Position 1: irrigation flow
 Position 2: aspiration and irrigation
 Position 3: irrigation, aspiration and ultrasonic
fragmentation

26. Continuous mode
• Continuous US energy
with no off period
• Linear control of
phaco power with
foot pedal
• Maximum power
preset
• Pedal depressed:0%
power  preset
maximum
Pulse mode
• Alternating phaco on-
off periods
• Linear control of
phaco power with
foot pedal
• On-time
automatically
followed by off-time
• Reduced power by ½
Burst mode
• Specific and identical
bursts of energy
• More rapidly 
interval small
• True phaco assisted
aspiration of the lens
nucleus
• Very short power
• Lower phaco power

28. Incisions Description
Limbal
Incision position: Limbal preincision perpendicular to plane followed by
direct incision toward the anterior chamber which is slightly angled
size: 3-3.5 mm
Equipments Used: 150 Straight knives
Clear Corneal
Tunnel
Incision position: Vertical Incision is done in cornea then entering the AC
with a parallel plane to iris
Shape: Squared tunnel same length same width
Size: 2.8mm to 4mm for foldable Lenses 5.5 to 6.5 mm for rigid
Microknife with 30 blade: for vertical preincision and lateral incisions
Equipments Used: Disk microknife: for delamination of the intra cornea
3.2 mm lancet microknife: for entrance of Anterior Chamber
Microknife: for widening the incision for implantation

29. Incisions Description
ScleraTunnel
Incision position: Incision is constructed about 2mm away from
limbus perpendicular to sclera then sclero-corneal pouch is cut
followed by oblique entrance incision
Size: 3.5 to 7.00 mm depend on IOL style
Equipments Used:
Microknife: external Sclera
Crescent Microknife with angle blade :for intra scleral dissection
Angle blade : entrance of Chamber
30°angle blade :for lateral incisions
5.2 angled microknife : IOL implantation
Side Port Incision
Position of incision: 300 to 450 away from entry wound
Size: 1mm
Stab type: 15° angled knife
For manipulation or for viscoelastic entry

30. Style Advantages Disadvantages
Scleral Rarely induces astigmatism
Seals nicely
Technically difficult
Iris prolapse more common
Conjunctival manipulation &
cautery
Instruments distort cornea
Red eye after surgery
Cornea Rare astigmatism
No cautery or conjunctival
manipulation‐ Avoidance of
any vascular tissue
Self sealing wound
Technically difficult
Instruments distort cornea
Possible increased risk of
endophthalmitis
Limbal Easy to convert to ECCE
Instruments don't distort
cornea
Astigmatism
Always requires suture
Iris prolapse more common
Conjunctival manipulation &
cautery

31. Making an incision around the anterior
capsule using a cystotome (sharp, small,
sterile, mostly an insulin needle) in a BSS or
VES filled chamber.

32. There are 5 common variations of
capsulotomy:
 Can opener
 Postage stamp
 Christmas tree
 Envelop (linear)
 Continuous circular capsulotomy or Capsulothexis

33. Multiple small tears or punctures
Circumferential to the equator,
Diameter of 5-7 mm starting from 2 o’clock.
Then the cut capsule is removed

34. Continuous, symmetrical, linear opening of the anterior capsule
Instruments: cystotome + forceps
Steps :
 Initial aperture on the anterior capsule extending 2 to 3 mm
 Clockwise rotation of the cut capsule reaching the 6 o’clock position.
Presence of a viscoelastic agent
Ideal size for the produced rhexis: 5 to 6 mm

35. Hydrodissection
 The infusion fluid is injected
between the anterior capsule
and the cortex
 This separates the capsule
from the rest of the nucleus
 Facilitates nucleus rotation and manipulation in
Phacoemulsification
Indicators of successful Hydrodissection
 Shallowing of anterior chamber
 Free rotation of nucleus

36. Hydrodelineation
 The infusion fluid is
injected between the
epinucleus and nucleus
 Fluid wave appears as a golden ring under the
surgical microscope
 Hydrodelineation debulks the nucleus

37. Techniques Kelman Pupillary plane Maloney
Nucleus type Soft and Hard Middle hard -
Incision limbal Posterior limbal Scleral tunnel
Capsulotomy Christmas tree Can opener Can Opener
Viscoelastics not used not used not used
Hydrodissection n/u separation by
topical maneuvers
n/u separation by
shaving
n/u separation by
shaving concave
nucleus
Processes of
emulsification
SectorTechnique By means of spatula
and U/S
By means of spatula
and U/S
Rotation of Nucleus Moved to AC by U/S Moved to Pupillary
plane by U/S
Moved to posterior
Chamber by U/S
IOL implantation AC Posterior Chamber Posterior Chamber
lens
Suture 8-10 Silk multiple 8-10 Silk multiple 10 Nylon continuous

38. Techniques One handed
Endocapsular
Intercapsular Cut and Suck Chip and flip
Nucleus type Soft and slightly
hard
Moderate low
hardness
moderate low
hardness
slight moderate
hardness
Incision Scleral or corneal
tunnel
Scleral -corneal
tunnel
Scleral or
corneal tunnel
Scleral -corneal
tunnel
Capsulotomy Capsulorhexis Mini oval
Capsulorhexis
Capsulorhexis Capsulorhexis with
small diameter
Viscoelastics Used Used Used Used
Hydrodissection Applied Applied with
hydrolineation
Applied Applied
Processes of
emulsification
Sculpting Central sculpting removal of
superficial layer,
then deeper,
lateral
Applied with
hydrolamination
Rotation of
Nucleus
Nucleus pushed and
rotated inside
capsule by U/S
Nucleus pushed and
rotated inside
capsule by U/S
Moved to
Pupillary plane
by U/S
Carving and
shifting
IOL
implantation
In capsular bag In capsular bag In capsular bag In capsular bag

39. Technique Divide and conquer Stop and Chop
Nucleus type Moderately Hard-Hard Moderately Hard-Hard
Incision Limbal Sclerocorneal, scleral or
cornealTunnel
Capsulotomy Capsulorhexis (4.5-5.5 mm) Capsulorhexis
Viscoelastics Used Used
Hydrodissection accurate until rotation is
achieved
Necessary
Processes of
emulsification
Nucleus separation to 4
quadrants each one is
tipped up and emulsified
Breaking nucleus into two
Rotation of Nucleus Stabilized and rotated with
spatula and U/S
By means of chopper and
U/S
IOL implantation in capsular bag In capsular bag
Suture If necessary If necessary

40. Technique Advantages Disadvantages
Divide and conquer Classic easy to do
Energy away from
cornea
Can be done with one
hand
Lots of ultrasound
power
Stop n Chop Fairly easy to do
Less ultrasound power
Needs two hands

41. During sculpting: vacuum setting of 0 mmHg,
aspiration flow rate of 15-22 cc/min and maximum
power of 70%
For soft nucleus aspiration: vacuum setting of 70
mmHg, aspiration flow rate of 15-22 cc/min and
maximum power of 70%
For hard nucleus aspiration: vacuum setting of 150
mmHg, aspiration flow rate of 15-22 cc/min and
maximum power of 70%

42. The equilibrium between irrigation and aspiration
has to be maintained in order to preserve the
stability of the chambers
BSS solution used for I/A
The amount of irrigation flow depends on:
 Diameter of the irrigating tube
 Diameter of the connections
 Size of the orifices in the tip
 Height of the irrigating bottle

43. The aspiration depends on:
 Diameter of the tube and orifices
 Level of vacuum set on the machine

44. Maximum vacuum: 0.2 to 0.3 mm
Minimum vacuum: 0.5 to 0.7mm
Ideal orifice: 0.3 mm diameter
 Small to tear the posterior capsule
 Maintains good balance betweenA/I
 Easily captures the cortex.
Silicone sleeves preferable:
 Soft
 No affect to the walls of the chambers
 No light reflection from the microscope as metals do.

45. After emulsifying the nucleus and cortex:
 Aspiration process requires capturing them when
tip is in direct contact  foot pedal position 2
If the anterior capsule is captured 
weaken the zonular fibers
If the posterior capsule is captured
jeopardize the whole operation.

46. If the capsule was to be accidently capured:
 Avoid any movement with tip on the captured
capsule
 Interrupt aspiration
 Activate venting, move the pedal to position 0
 If the vacuum was too fast, activate reflux

47. Make the capsule completely transparent for
functional recovery
Remove all the cortex material to reduce the
spontaneous re-absorbance and inflammations
Remove all the usedVES at the end of the operation
Eliminate as many proliferative
cells as possible to avoid
secondary opacification of the
posterior capsule

48. After removing the cataract and cleansing of the capsule, the
intraocular lens is inserted, preferably in the capsular bag.
The lens must be:
 Biocompatible as not to trigger any inflammatory response
 Chemically and physically stable on the long run
 Light weighted

49. Classification of IOL based on fixation:
 Angle fixation: anterior chamber lenses
 Iris fixation: supported by the iris
 Mixed fixation: irido-capsular fixated lenses
 Posterior ciliary sulcus fixation: supported by the
ciliary groove
 Capsular fixation: inside the capsular bag
 Scleral fixation: located behind iris with no
support, held by sutures

50. Classification of IOL based on lens material:
 One piece lenses: non foldable PMMA or the
foldable silicone, acrylic, hydrogel….
 Two or three piece lenses: optic part is made up of
PMMA or silicone and the loops in prolene or
extruded PMMA

51. During the insertion of the lens it is important to:
 Have a deep capsular bag by insertion ofVES
 Avoid damaging the Descemet’s membrane, the
endothelium, the iris, the posterior capsule.
 Avoid lacerating the rhexis and the zonular fibers

52. IOL optic geometry evolved from planoconvex to
biconvex
Multifocal lenses innovation  adequate refractive
correction
Choosing appropriate IOL power before implanting
 Depends on the corneal refracting power
 Postoperative anticipated distance: anterior surface
of the cornea ↔ IOL
 Axial length of the eye.
Post IOL insertion
 Total removal of the viscoelastic solution
 Irrigation with BSS

53. All viscoelastic must have high viscosity at zero shear rates
for stabilizing the tissues of the eye during surgery
They are transparent and easily injected, due to their
pseudoelasticity.
Visco is commonly made of hyaluronic acid differing in their
concentration, molecular weight, and length of chain from
one product to another.

54. Cohesive with high molecular weight and high viscosity
 Help maintain a stable nucleus during Capsulorhexis
 Deepening of chamber
 Opening the capsular bag
 Maintaining space for IOL implantation
 Creating counter pressure on the vitreous.
Dispersive with low viscosity and low cohesiveness
 Break up easily when injected in the eye
 Adhere to the tissues
 Protect the endothelium
 Capture nuclear fragments.

55. Filling the anterior chamber
 Transparent, easy to inject viscoelastic
 Maintain space due to its high viscosity with zero
shear rate
Capsulorhexis
 Deep anterior chamber: substance of high molecular
weight and high viscosity
 Transparency
 Stability of the capsular flap: highly cohesive
viscoelastic
 Easy manipulation of the instruments: pseudoelastic
and highly elastic viscoelastic

56. Nuclear and cortical fragmentation
 Elasticity to resist applied forces and mechanical
vibrations
 Adhesiveness to protect surrounding tissue (due to I/A)
 Maintain space and doesn’t escape due to low
cohesiveness
 Persist AC due to low Cohesiveness
Filling the capsular bag
 Easy to inject due to high pseudoelasticity
 Allow good visibility
 Easy to remove when IOL implanted
 High cohesiveness

57. Bring edges of the incision together
Provide rapid recover
Aqueous proof
Avoid astigmatism

58. Interrupted sutures:
 Equidistant and radial sutures
 Made under the same tension
 Tightened to the same degree all over the incision with
the same depth and length.
Continuous sutures:
 Made from the beginning till
the end of the incision
 Reducing the number
of knots.
 Oblique, isosceles or perpendicular to the incision.

60. Rupture of posterior capsule
Prolapse of vitreous requiring vitrectomy
Hemorrhage
Dislocation of lens fragment in vitreous : if capsule is ruptured
Inadequate support for lens implantation, requiring use of an
alternative type of lens implantation or postponing or abandoning
lens implant
Pain & increase in the eye pressure or glaucoma post-operatively
Infection or endophthalmitis which may require injection of
antibiotics into the vitreous or even vitrectomy surgery. Caused by
infectious organisms from the patient’s own body or from fluid used
during surgery
Corneal edema
Refractive error and astigmatism
Wound leak
Inflammation or uveitis
Secondary cataract