Phacoemulsification part 3

PHACOEMULSIFICATION
PART III
BY- PRIYANKA RAJ

◦ With improvements in IOL delivery systems in the mid-1990s, it became possible to
perform the entire phaco procedure with lens implantation through an incision of 3 mm
or less.
◦ INSTRUMENTS
1. 15 degree blade
2. keratome (2.8 mm to 3.2 mm and 5.2 mm)
3. crescent knife
◦ PRE-REQUISITES
◦ Sharp instruments and a tense eyeball
◦ Viscoelastic substance (VES) from the side port to obtain adequate IOP of 30 mm Hg
before starting the incision.

SIDE PORT INCISION (SPI)
◦ Site 2 to 3 clock hours away from the main incision
◦ Size 1 to 1.5 mm.
◦ A clear corneal square tunnel is preferable.
◦ A scleral tunnel
1. bleed more
2. increases the incidence of iris prolapse, being closer to the iris root
3. Sclera does not swell retracts increasing the incidence of wound leak.
◦ Instrument 5 degree blade.

◦ Technique
◦ Enter with the knife pointed towards the ciliary body 150 degree to 180 degree away
creating a uniplanar 1.5 mm × 1.5 mm square tunnel.
◦ Counter pressure by a toothed forceps/chopper can be applied on the other side to
assist this.
larger tunnel iris prolapse and unstable chamber
tight tunnel localized corneal whitening or edema.

MAIN INCISION
◦ classification by Fine
1. clear corneal incisions with an external entry anterior to
the conjunctival insertion.
2. limbal incisions made through the limbus
3. conjunctival insertion and scleral corneal incisions those
posterior to the limbus, usually requiring a peritomy.
◦ Construction square or “nearly square” configuration
prevents hypotony in the early postoperative period
◦ Astigmatic Considerations
1. approach the eye from a temporal location and then perform
limbal relaxing incisions when necessary in the steep axis
2. Make incision on the steep corneal axis and then make
limbal relaxing incisions, as needed, opposite and adjacent
to the incision

CLEAR CORNEAL INCISION
◦ Types of Corneal Incision
1. Uniplanar
2. Biplanar
3. Triplanar
4. Hinged

Triplanar incision
◦ The initial vertical cut is made with a No. 11 blade or a 15º knife.
◦ 500 μ deep + 3–3.5 mm in width.
◦ The dissection is done with a crescent knife.
◦ Inner lip is straight and parallel to the initial incision.
◦ viscoelastic is injected into the tunnel and AC entered with 3.2 keratome.
◦ Advantage  a well controlled incision with an excellent valve.

Hinged incision
◦ Initial groove is 600 μ or more and the tunnel is
made at 300 μ as in the triplanar incision.
◦ The valve action is considered to be better.
Biplanar corneal incision
◦ After the initial groove, the keratome is used
directly to make 1.75 mm corneal valve and then
the direction is changed to enter the AC (no
crescent knife is used).
Unilplanar clear corneal incision
◦ Incision is made in a single plane.
◦ Advantage The post-operative irritation is
reduced.
◦ Disadvantage outer flap is very thin and tends to
roll into the tunnel with the introduction of phaco
probe (this may result in corneal burn).

LIMBAL INCISION
◦ good compromise between a clear corneal and a posterior limbal incision.
◦ Incision should be made at the limbus with minimal oozing, if at all and minimal
disturbance to the conjunctiva.
◦ Bleeding usually stops by the end of surgery and chances of corneal burn are less (
particularly in hard cataract).
◦ As in CCI, the incision may be uniplanar/biplanar/triplanar or hinged.

Approach to the Scleral Corneal Incision
◦ Perform a Peritomy.
◦ Create a Scleral Groove and Scleral Tunnel
◦ scleral groove 1 to 2 mm posterior to the limbus at a depth of approximately 250µ
◦ The width of the scleral groove equal to or only slightly wider than the width of the
keratome
◦ Using a “crescent blade,” create a scleral tunnel by dissecting into clear cornea at
least 1.5 mm anterior to the limbus
◦ Internal Incision Using a keratome that is precisely matched to the width of phaco
tip, direct the blade parallel to the iris plane and enter the anterior chamber at the end
of the scleral tunnel

Problems with incision
◦ SIZE
1. The use of a keratome that is too narrow for the phacoemulsification instrument may
lead to restriction of flow through the irrigation sleeve, overheating of the phaco tip,
and thermal injury to the incision.
2. The use of a keratome that is too large results in excessive outflow around the
irrigation sleeve and difficulties with anterior chamber maintenance during the
procedure.
◦ Torn edges
◦ common with a corneal tunnel, particularly during the enlargement.
◦ due to failure to understand the curvature of cornea.

◦ Premature entry
◦ more common in clear corneal incision because of the use of sharper knife.
◦ most frequently seen in uniplanar incision.
◦ Long tunnel
◦ Commoner in soft eyeball like myopes/inadequate viscoelastic
◦ if the knife is blunt.
◦ Leaky wound
◦ Increased length of the incision
◦ Premature entry

CONTINUOUS CURVILINEAR CAPSULORRHEXIS (CCC)
◦ capsular bag diameter 10 to 11 mm.
◦ Zonular fibers are attached to the lens capsule in a criss-cross pattern at the equator,
anterior and posterior surface of the lens, and leave about 6–7 mm of central capsule
clear.
◦ PHYSICS OF CAPSULORRHEXIS
◦ Types of force
1. Ripping: tear obtained is uncontrolled.
2. Shearing: In this, one fibre is broken at a time the tear is more controlled and
requires much less force.
3. Tangential force: The direction of tangential force is continuously changing.
Movement of the needle should be curvilinear along the proposed margin of CCC
(nearly super-imposing

PRE-REQUISITES
1. Good akinesia
2. Moderate- minimal Hypotony-
Approximate IOP should be 25-30
mmHg
3. Good red reflex
4. SIZE OF CCC should cover the optic
of the IOL by 0.25 mm circumferentially
(about 5mm diameter)
5. INSTRUMENTS
◦ Cystitome
◦ ForcepsUtratta forceps
6. Dye: Trypan Blue

STEPS:
1. Select the Optimal OVD(s) for the Specific Case
2. Begin the linear cut Centrally 1.5 mm in length
3. Create a Capsular Flap. curvilinear extension of approximately 1 mm.
4. Grasp the Flap and Begin the Curvilinear Tear needle is kept on the line of
proposed CCC approximately 1 mm away from the cut end.
◦ Young eyes The capsule is more elastic and less “brittle” in young eyes. It is
sometimes necessary to pull in a direction 90 degrees from the direction of the tear
◦ Forceps
◦ Advantage: fibrotic, atrophic and elastic (i.e. pediatric) capsules and in soft cataract
with high intra-lenticular pressure (morgagnian and intumescent) where one is not
able to get a good counter pressure.
◦ Disadvantage: wound leak and distortion of cornea

PROBLEMS
◦ Problems in Initiation
◦ Disturbence of cortex
◦ Blunt needle triangular flap.
◦ too small or eccentric CCC “two-staged CCC”. start a new tear in the edge of an
existing opening, a scissor is used to make a very short tangential cut. The new
beginning flap is then grasped with forceps and the new tear is continued around the
circle of desired diameter

HYDRODISSECTION
&
HYDRODELINEATION

◦ AIM: to divide the cataractous lens into 3 distinct zones.
1. Capsule with or without cortex
2. Epinucleus
3. Nucleus
◦ Purpose:
1. facilitates rotation so that the nucleus and epinucleus can be rotated and
brought into the direct line of attack.
2. The Epinuclear plate created acts as a cushion, protecting the PC during
phacoemulsification.
3. Hydrodelineation also decreases the size of the nucleus, thus enabling prolapse
of nuclear fragments out of the rhexis margin, into the Central Safe Zone (CSZ)
for phaco aspiration.

HYDRODISSECTION
◦ Hydrodissection is the separation of the cataractous lens from the capsule by a
mechanical fluid wave.
◦ Pre-Requisites
◦ The first step is to partially remove the viscoelastic from the chamber, especially if
one has used higher viscosity agents like Healon GV and Healon.
◦ The fluid injected tends to move the lens forward and if there is already viscoelastic in
the AC, the force will be transmitted to the posterior capsule increasing the chance of
rupture.
◦ SITE:
◦ Hydroprocedures are performed through the main entry.
◦ bent cannula start 90° away from the main port.
◦ straight cannula start 180° away from the main posrt.

TECHNIQUE
1. The cannula under (2–3 mm) the CCC as close to the anterior
capsule as possible
2. tenting the capsule upwardfluid is injected with a jerk (for wave
formation)
3. wave becomes visible along the PC SLOW DOWN
4. when the wave is visible posteriorly, at the end opposite to where
injection was InitiatedSTOP
5. lens comes anteriorly+ the CCC gets stretched & enlarged+ the AC
becomes shallow
6. compression hydrodissection gentle pressure on the centre of the
nucleus will release the fluid forward CCC returns to normal size
7. Modified compression hydrodissection Sinskey hook/chopper
close to the CCC margin on one side, move the nucleus to the opposite
side and then press slightly downwards for release of the fluid

Special Situations:
1. Small CCC
◦ chance of fluid entrapment under the CCC is high.
◦ avoid a complete wave and instead perform minihydros at multiple sites.
2. large CCC
◦ tendency for the nucleus to prolapse into the AC.
◦ reposit the nucleus back into the bag unless supra-capsular phaco is planned.
3. Eccentric CCC
◦ inject such that fluid can come out of the normal side without entrapment or prolapse.
4. Hypermature Morgagnian cataract
◦ require minimal or no hydrodissection.
5. Posterior Polar Cataract
◦ No hydrodissection should be done

HYDRODELINEATION
◦ AIM:
◦ to create the smallest possible nucleus with the thickest possible
epinuclear plate.
◦ results in minimal use of phaco power with the maximal cushioning
effect.
◦ Technique
1. cannula is embedded into the centre of the nucleus (without pushing it
backwards) and simultaneously advancing towards the CCC margin.
2. Once well under the CCC margin, the cannula is directed slightly
obliquely vitreousward and towards the periphery and fluid is injected
with a jerk
3. golden ring reflex or a gray reflex is seen.
4. The posterior separation is usually quicker while the anterior fibres
may remain adherent which may get separated by pushing the
nucleus down—compression delineation.
◦ Note: some amount of viscoelastic over the CCC may help in directing the
fluid wave into the substance of the lens and delineating the nucleus.

Rotation of the nucleus
◦ Single-handed rotation
◦ Sinskey hook or with a chopper
◦ 2–3 clock hours is sufficient to confirm the mobility.
◦ Mobility confirmed rotate it back to decrease the stress on the zonules.
◦ Unnecessary rotation can cause zonular dehiscence particularly in
susceptible cases such as high myopes, pseudoexfoliative syndrome and
traumatic cases
◦ Bimanual rotation
◦ 2 Sinskey hooks or 1 Sinskey hook + 1chopper
◦ positioned 180° apart pushed towards each other to get a grip on the nucleus.
◦ They are thenmoved in opposite directions to rotate

Classification
PHACO
TECHNIQUES
Phaco in anterior
chamber
Phaco in pupillary
plane
Phaco in posterior
chamber
Supracapsular
phaco

PHACO IN ANTERIOR CHAMBER
PHACO IN
AC
Croissant
technique
Carousel
technique
Sectors
technique

Phaco in Pupillary Plane
◦ Also known as Little’s technique (1979).
◦ Four basic strategies are followed:
◦ Central fragmentation in situ.
◦ Subluxation of nucleus in pupillary plane.
◦ Equatorial fragmentation (sectorwise).
◦ Fragmentation of residual central nuclear material.

Endocapsular Techniques of Phaco in
Posterior Chamber
Without
Nucleofracture
• Shepherd’s
technique.
• Intercapsular
technique.
• Cut and Suck
technique.
• Chip and Flip
technique
Mixed techniques
of nucleofracture
• Divide and
Conquer
• In situ fracture
• Downslope
sculpting
• Fractional 2:4
Technique
• Crack and Flip
Technique
Pure Nucleofracture
Techniques
• Phaco Chop.
• Bevel down Phaco
(Phaco Drill).
• Choo-Choo Chop.
• Phaco Quick
Chop.
• Lensquake
Technique

One-handed Endocapsular Phaco (Shepherd’s
Technique)

Divide and Conquer
◦ Introduced by Gimbel (1986)
◦ most versatile and reliable of all
methods for nuclear disassembly
◦ Most commonly used by beginners
Divide and conquer—forces are
radial and centrifugal.

◦ Divided into 4 steps:
◦ Deep central sculpting.
◦ Fracture of the disc.
◦ Rupture of a wedge shaped
section and its emulsification.
◦ Rotation of the nucleus for
emulsification of another wedge.

MODIFIED DIVIDE AND CONQUER
◦ STEPS
1. Sculpt the Nucleus
2. Deepen the Grooves.
3. Complete Grooves Before
Cracking
4. Crack the Nucleus Into
Quadrants
5. Phaco the Quadrants The phaco tip and the cracking instrument
should be placed at the base of the groove.
Separation of the instruments results in bidirectional
forces at the base of the groove and nuclear fracture.

ADVANTAGES
1. Requires Less Bimanual Manipulation and Lower Vacuum Setting
2. Relies Primarily on Visual Assessments
3. More Protective of the Corneal Endothelium
4. Useful for Nuclei of All Densities

Phaco Prechop
◦ Devised by Takayuki Akahoshi.
◦ Technique of nuclear fracture prior to
phacoemulsification.
◦ Nucleus divided without grooving or
sculpting.
◦ Two main techniques:
◦ Karate Prechop
◦ Counter Prechop

Karate Prechop
◦ Used for soft nuclei.
◦ A special instrument (cross action
forceps) called Prechopper is used.
◦ Various Prechoppers in use are:
◦ Combo Prechopper
◦ Universal Prechopper
◦ Paddle Prechopper
◦ The Prechopper has 2 blades, one blunt
and the other sharp.
◦ It is inserted into the nucleus and
divides the nucleus into 4 fragments
before phacoemulsification.

Counter Prechop
◦ Used for hard nuclei, cases with weak
zonules.
◦ A second instrument called Nucleus
manipulator is there to support the
nucleus and provide counter force to
the prechopper during its insertion.
◦ The nucleus manipulator has a
long tip that supports the nucleus
at the deep equatorial region.
◦ A microball at its tip protects the
posterior capsule.

◦ After prechopping, phacoemulsification is completed with
high flow and high vacuum settings.
◦ Phaco time and total energy used are considerably
decreased.
◦ No thermal damage.

PHACO CHOP TECHNIQUES
◦ Kunihiro Nagahara of Japan first introduced the concept of phaco chop in 1993
◦ all chopping methods be conceptually divided into two general categories: horizontal
and vertical chopping.
◦ Both variations share the same advantage of manually fracturing the nucleus but they
accomplish this objective in different ways.
◦ The stop and chop method of Paul Koch is a hybrid of divide and conquer and
chopping, which avoids having to make the difficult first unsculpted chop
◦ COMMON ADVANTAGES:
◦ Reduction in Phaco Energy and Heat Delivery
◦ Reduction in Stress on the Zonules and Capsular Bag
◦ Supracapsular Emulsification
◦ Decreased Reliance on the Red Reflex

HORIZONATAL CHOP
◦ relies upon compressive force to fracture the
nucleus.
◦ This exploits natural fracture planes in the lens
created by the lamellar orientation of the lens fibers.
◦ Hydrodelineation important decreases the
diameter of the endonucleus that must be
peripherally hooked and divided by the chopper.
◦ Soft epinucleus provides a working zone for the
horizontal chopper where it can be manipulated
peripheral to the endonuclear equator without overly
distending or tearing the capsular bag.
◦ The epinuclear shell restrains the posterior capsule
from trampolining toward the phaco tip as the final
endonuclear fragments are emulsifie
Horizontal chop—forces are radial and
centripetal.

STEPS:
1. Place the Chopper Tip in the
Epinuclear Space
2. Impale and Immobilize the Nucleus
With the Phaco Tip.
3. Execute the First Chop.
4. Remove the First Chopped Fragment
5. Chop and Phaco Additional Nuclear
Segments

VERTICAL CHOP
◦ initiating horizontal chop by first hooking
the nucleus with the chopper tip.
◦ With vertical chop, the nucleus should
first be impaled with the phaco tip.
◦ STEPS:
◦ Impale the Nucleus With the Phaco
Tip
◦ Incise the Nucleus With the Vertical
Chopper, Then Lift With the Phaco
Tip.
◦ Chop All Fragments Before
Removing Them.

After rotating the nucleus 30 degrees counterclockwise, the nucleus is impaled with 400 mmHg vacuum. The
vertical chopper descends into the nucleus, resulting in propagation of the fracture.

Stop and Chop
◦ Devised by Paul Koch in 1993.
◦ Disadvantage of Phaco Chop was lack of space in the bag
to remove the broken fragments.
◦ An initial space is created by sculpting and then chopping
becomes easier.

Four Before Phaco
◦ Devised by Dr. Kammann.
◦ Used for red-brown nuclei employing mechanical division without ultrasound
energy.
◦ Two 2.5 mm long Sinsky hooks are used for fragmentation.

Supracapsular Phacoemulsification

ASPIRATION PHACO
◦ The removal of divided nucleus segments from the capsular fornices and their
aspiration in the central safe zone ( CSZ ) is called aspiration phaco
◦ With improvement in the fluidics of the machine, more of aspiration and less of phaco
power is used.
◦ The aim is to perform the surgery in such a way that there is minimal keratitis or
complications, irrespective of the hardness of the cataract, the pupil size,
anterior chamber depth and corneal health.

◦ Settings
◦ Power settings depend upon the grade of nucleus and can be further controlled by
the foot pedal.
◦ A 30% reduction in power setting from that kept during trenching
◦ Pulse mode reduces the consumption of phaco energy by half and allows adequate
time for vacuum build up during the interval when the phaco is off.
◦ Pulse settings between 2 to 6 is ideal for this procedure.
◦ Vacuum settings depend upon the type of cataract and the space in the anterior
chamber.
◦ hypermetropic eyespace in AC is less low vacuum settings
◦ myopic eyes  enough space and high vacuum settings are possible.
◦ Small pupil and small CCCrequire stronger grip and higher vacuum settings to pull
the pieces into CSZ in the first attempt

Problems
◦ Inability to remove the nucleus piece
◦ capsular fornices
◦ Burrowing of fragment
◦ Continuous use of phaco energy leads to through & through emulsification of the
nuclear fragment
◦ Milking
◦ due to partial or complete clogging of the aspiration system.
◦ Therefore, there is low vacuum delivery.
◦ The nucleus gets emulsified but not aspirated leading to clouding of the chamber.
◦ Chattering
◦ more common with small hard cataract pieces
◦ seen when too much power is used with a poor hold on the fragments.
◦ Pieces lodged in no/low followability zone

EPINUCLEAR PLATE REMOVAL
◦ Applied:
◦ size of epinuclear plate is very large vis a vis the CCC. Cannot be prolapsed into AC
◦ For practical purposes the plate consists of 3 parts
1. anterior(beneath the anterior capsule)
2. equatorial (at the capsular fornices)
3. posterior (along the posterior capsule).
◦ INSTRUMENTS
◦ Iris Repositor through the side port

◦ Phaco Settings
◦ depend upon the hardness of the epinuclear plate.
◦ Recommended:
◦ power of 20+/-10 %
◦ Flow rate 30+/-6
◦ Vacuum of 250+/-100 mmHg.
◦ TECHNIQUE: chip and flip

Chip and Flip Phaco
◦ Devised by Dr. Howard Fine.
◦ Allows phaco tip to be consistently far away from posterior
capsule.
◦ Pulsed phaco is used.
◦ First central sculpting is done.
◦ The inner rim of nuclear bowl is removed.
◦ The outer nuclear bowl is flipped/ tumbled away from the posterior
capsule.

types
1. Co-axial irrigation aspiration system
◦ an aspiration orifice in front and the tip
may be straight or angulated (45° to
90°)
◦ size of the orifice 0.2–0.7 mm, (0.3
mm most commonly used)
◦ tip is covered by irrigation sleeve which
may be detachable (silicon)or fixed
(metallic), with two openings 180° away
from each other.
2. Bimanual irrigation-aspiration (IA)
system
◦ two handles one with aspiration cannula
and second one with irrigation cannula
with two orifices on either side

◦ Three-Piece Silicones Single-Piece Acrylics

◦ Bausch & Lomb LI 61
◦ EZ-28 Disposable Injector/Cartridge Unit

REASONS TO CONVERT
◦ Most common reason for conversion is PCT..
1. CCC related problems
1. Small CCC (< 4.5 mm) and large nucleus—All steps will be difficult to do
2. Too large CCC—Nucleus will prolapse in to the AC and phaco will be difficult.
3. Discontinuous CCC—A discontinuous CCC may be due to inability to make a CCC
or Rehxis margin tear (RMT) during any step.
2. Excessive use of phaco and fluids (Prolonged surgical time)
3. Wound related problems (leaks)
4. Corneal edema
5. Intraoperative miosis
6. Improper case selection

INTRA OPERATIVE
◦ Wound related
◦ Iris prolapse
◦ Corneal
◦ Descemet’s membrane detachment
◦ Corneal burns
◦ Anterior chamber
◦ Iridodialysis
◦ flattening of anterior chamber
◦ Hyphema
◦ Intraoperative floppy iris syndrome
◦ Lens related
◦ Dropped nucleus
◦ Retained lens mater
◦ Posterior loss of lens fragments
◦ IOL related
◦ IOL dislocation
◦ Posterior segment
◦ Posterior capsule rupture
◦ Cyclodialysis
◦ Suprachoroidal effusion & hemorrhage

EARLY POST OPERATIVE
◦ Wound related
◦ Wound leak
◦ Iris prolapse
◦ induced astigmatism
◦ Corneal
◦ Corneal edema
◦ Striate keratopathy
◦ AC reaction
◦ Hyphema
◦ TASS
◦ Vitreous in AC
◦ IOP related
◦ Raised
◦ Low
◦ IOL related
◦ Decentered
◦ Dislocated
◦ Tilted
◦ Pupillary capture
◦ Capsular block syndrome
◦ Acute Endophthalmitis

Late post operative
◦ Wound related
◦ Astigmatism
◦ Corneal
◦ Bullous keratopathy
◦ Corneal decompensation
◦ Corneal melting
◦ Brown-McLeansyndrome
◦ Epithelial down growth
◦ IOP related
◦ Glaucoma
◦ Chronic uveitis
◦ UGH syndrome
◦ Iris atrophy / cysts
◦ IOL related
◦ Malposition, glare
◦ PCO & Phimosis
◦ Posterior segment
◦ Retinal light toxicity
◦ Macular infarction
◦ CME
◦ R/D
◦ Chronic Endophthalmitis

Phacoemulsification part 3

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Phacoemulsification part 3